HEALTH AND IMMUNISATION QUIESTIONNAIRE

Foreign students coming to study in Croatia and applying for student's dorms are required to undergo health
examination in order to determine and reduce health risks for dormitory living conditions.
Students are asked to bring doctor's report of pre-existing and existing health issues with the emphasis on
chronic and contagious diseases.
The document should give details on vaccinations. Adequate immunization against Morbilli-Mumps-Rubeola
(MMR), Tetanus-Diptheria-Pertussis (TDP, TDaP) and Hepatitis B (Hep B) is required.
Mantoux test (TB) date and result not older then 6 months is obligatory (except EU citizens).

Rodrigo
Name : ______________________________________________
Rivas Basic
Surname : ____________________________________________
08/01/1998
Birth date: _____________________ Sex: X
M F
Calle 6 #250 Córpac, San Isidro, Lima, Perú
Address, City, Country: _____________________________________________________________
+51 921927215
Telephone or Cell Phone Number: ___________________________________________________

HEALTH STATUS (administered by MD)

Please list pre-existing and current medical conditions of the student and if none please indicate so.
Doesn't have any preexisting or current medical conditions.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

IMMUNIZATION STATUS
Vaccine Dates of given doses
DTP 14/03/98 29/01/00 29/01/01
DT
OPV, IPV 10/02/98 14/03/98 29/01/00 29/01/01
MMR 29/01/00 29/01/01 11/06/02
Hep B 27/02/99 27/03/99 04/09/99
Hib
BCG 09/01/98
Mantoux test
(result in mm)

WITH THIS SIGNATURE I CONFIRM THAT STUDENT HAS NO CONTRAINDICATIONS TO LIVE IN A DORM:

DATE MD PRINTED NAME MD SIGNATURE

01/09/2023
_____________ ___________________________________ ________________________