2023 nrxrct nrp'-rl Health Declaration

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Name of Medical Facility:

Gountry:

Dear doctor,
The applicants intended to work in lsrael must be healthy and without disabilities, who have
not suffered in the past from serious, chronic illness or disability. Applicants arriving in Israel
with pre-existing medical conditions or disabilities will not be covered by lsraeli medical
insurance. Without insurance, medical costs will be very high; applicants will only be able to
receive emergencies treatment.

Address of medical facility:

Phone number of medical facility: Fax:

E- mail:

HEALTH CERTIFICATES
BASIC DATA

Ref. No. Date of Examination I I

Date Month

Name Passport No.

LD. No. Sex E MaletrFemale

Age Yrs. Weight in kg: Height in kg:

Date of Birth lt Marriage: tr Married DSingletr other

Month

Home Address
2 2023 nt,xtc'r nrp,-Tl Health Declaration

Name Passpoil No.

General Questions Yes No

Do you use or have you been using narcotics?

Do you drink, or have you been drinking alcoholic beverages regularly? Please
specify the quantity of consumption: olasses per dav

Do you suffer from any chronic diseases?

Have you been hospitalized in the last 10 years? Please describe in detail the
reason for hospitalization and the treatment that you have received:

During the last 10 years, have you been taking, or have you received a
recommendation to take medications regularly? PIease describe in details the
problem for which you are treated I have been treated, the treatment, and for
how long have you been taking the medication?

Have you ever been diagnosed with any allergies in the past?

PIease describe in details:

Have you had an accident before?

What extent were you injured in the accident?

ls your BMI higher than 25?

\ Are you pregnant now?

o
n Have you undergone a cesarean delivery in the past?
e
n
3 2023 nr,xror nlp''Il Health Declaration

Name Passpoft No.

MEDICAL HISTORY
Have you been diagnosed with any illness, syndrome, disorder related to one Yes No
or more of the issues specified below:

E-The nervous system ECerebrovascular accident (stroke) llEpilepsy

lnIultiple sclerosis EMuscular dystrophy or other atrophic disease
[Reoccurring dizziness EParkinson's syndrome
lAzheimerrs disease ETrembling EBalance disorders lfainting
Mental retardation E Rutism flCerebral palsy
!Poliomyelitis (infantile paralysis) f]Gauchens disease
1) Eloss of sensation (numbness) Euigraine
lttave you applied to a physician with complaints regarding declined
memory (dementia) EAIDS EHlv carrier ELupus lhypertension tr
Hemoptysis Edema flYaws ! Hemorrhoids fl F ractures

EOiaOetes mellitus EJaundice Evenereal diseases

lAcquired Immunodeficiency Syndrome EMalaria

Eyes and vision: f]Cataract flRetina and cornea problems LlGlauco

Elnflammations of the eye Estrabismus EBlindness
2l
f] Ottrer eye disease / problem: ENo !Yes, if - Yes - please specify:

Hearh ECardiac arrhythmias flHeart disease EHeart failure LlHeart

attack !Congenital heart defect ECatheterization
3)
Heart valve diseases, other heart disease / problem: Etto !Yes, if - Yes "
please specify:
Blood vessels: f]Varicose vein (in the veins of the legs) UCarotid artery (in
the arteries of the neck) lCoagulation disorders f]Blood disease DW
4)
(Thrombosis) EPVD (Peripheral Vascular Disease) other vascular disease /
problem Etrlo !Yes, if - Yes - please specify:
 2023 nrxtc-l ntp,'Tl Health Declaration

Metabolic diseases f,Thyroid gland I

Salivary gland Elymph node E
sweat gland leituitary gland [Diabetes lHypertension lHign revers of
5)
cholesterol/fat, other metabolic disease / problem Ewo f]yes, if - yes -
please specify:
Respiratory system: l_JAsthma ETuberculosis ECOPD (chronic
obstructive pulmonary disease) EHay fever f]Recunent respiratory
infections and Shortness of breath lcoltapsed lung (Pneumothorax)
6)
ECystic Fibrosis
Other respiratory system disease / problem Eruo [Yes, if - Yes - please
specify:
Digestive system: Ulcer (duodenum / gastric) ECrohn's disease E
Hemorrhoids E Fissure / Fistula lBowel obstruction

7)
EPancreatic diseases / infections EEsophagus ECallOIaOder Ecall-
bladder stones
Other digestive system disease / problem Eruo !Yes, if - Yes - please
specify:
Liver: l__lJaundice lHepatitis B, C, D EFatty liver lCirrhosis,
8) Other digestive system disease / problem Eruo !Yes, if - yes - please
specify:
Hernia: Location of the hernia: ln the diaphragm / in the navel i in the right
groin / in the left groin
e) Have you undergone a surgery to treat the hernia? ENo !Yes, when
(date)?
ls the problem solved? Etto lYes
Kidney and urinary tract: [_]Recurrent infections EKidney and urinary
stones lXiOney cysts EAnomalies of urinary tract lRenal failure,
10)
other kidney and urinary tract disease / problem [trto !Yes, if - yes -
please specify:
Joints and bones: Arthritis EGout EBack / spine EJoints trKnees
111 Other
joints and bones disease / problem Etto EYes, if - Yes - please
specify:

skin and sexual diseases Est<in tumors Esrin lesions Epsoriasis

121
Esexually transmitted diseases lsyphilis EGonorrhea
other skin and sex diseases disease / problem Etto !Yes, if - yes - please
specify:
Malignant tumors / diseases (cancer): have you suffered from any type
13)
of cancer in the past? Please specify cancer type:
.5 2023 nr,xrct nrp,ll Health Declaration

For women: l_JGynecological system disease, [Breasts (including breast

enlargement)
other feminine problem Eruo EYes
14) Previously had a caesarean section Etlo lYes
If the candidate suffers from any diseases, please specify:

For men: l_JProstate problems lJVaricocele / Hydrocele

Other masculine disease / problem Eruo !Yes, if - Yes - please specify:
15)

Mental illnesses: Mental illness that was diagnosed by a psychologist,

16) psychiatrist or family physician

Nose, ear or throat diseases: l_lNo [JYes

171

Do you suffer from chronic conditions not mentioned in the

18)
questionnaire?

I hereby declare that the above answers are true and complete and given voluntarily,
and that I do not use medication on a daily basis.

I am aware that any material falsification or omission of fact results in my immediate

discharge from my employment in Israel.

I certify that I don't suffer from alcoholism and I am not an alcoholic and I do not
drink alcohol on occasionally nor do I use drugs and I understand, that appearing at
work after use of alcohol or drugs will lead to my discharge from work and
deportation.

Candidate's Signature Date

6 2023 nl,xtc-l nrp'll Health Declaration
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Name of Medical Facility:

Name of Applicant l.D. No.

Passport No

PHYSICAL EXAMINATION (To be filled in by physician)

Height
Pulse /min
Vision: Right left Eyes Ewitn glasses Ewithout
glasses
Color blindness Blood group

CHECK EACH ITEM IN APPROPRIATE COLUMN

ITEMS NORMAT ABNORMAT ADDlTIONALCOMMENTS

General appearance n tr
Skin, Scalp ! tr
Lymph nodes x !
Eyes D n
Ears: tr tr
Otoscopic Exam ! n
Nose n tr
Pharynx & Tonsils ! !
Thyroid gland E tr
Lungs E n
Heart ! !
Abdomen tr tr
Liver n !
Spleen ! !
Hernia ! !
External genital n tr
Rectal exam n E
Vertebrae E E
Locomotor tr !
Reflexes ! !
Mental health status I n

Others:
7 2023 nrxrct nrp'-Tl Health Declaration

LABORATORY EXAMINATIONS

White blood cell count .................. cells/cu.mm.

Differential: PMN..........% 1ymp...............% Mono .................%Eos .............. ..........%
Baso ............% Band ..............% Blast ...................%
Serological test for anti HIV ! GPA Test E Positive ENegative
EElisa Test nPositive ENegative
EWestern Blot Test tr Positive !Negative
Hepatitis B Surface Antigen TestnPositive ENegative
A NEIA BERIA c E Others.

Hepatitis C Virus Antibody !Positive ENegative

Serological test for Syphilis tr VDRL Test n Positive ENegative

tr RPRTest E Positive !Negative
tr TPHA Test tr Positive !Negative

Urine test Test for gonorrhea nPositive trNegative

Epithelial Cel|............/HPF. Others..

Urine pregnancy test (for female only) ! Positive ENegative

Chest X-ray for tuberculosis n Normal !Abnormal

Other examinations: Antihelminth drug receipt on...
Tetanus Toxoid 0.5 cc (m) on.........

Summary of Results of Electrocardiogram:

Reason for ending test:
Chest Pain:
Change in ST:
Problems and Summary:
 2023 nlxrc-l nlp'lt Health Declaration

I hereby confirm that after taking the medical history of the applicant,
Name passport No. (hereinafter: the
applicant) and examining the results of the above laboratory tests and physical
examination, I have found that the applicant is healthy, does not show signs of alcoholism
or drug abuse, has never in the past suffered from mental illness or severe or chronic
physical illness such as cancer or diabetes, and does not suffer currently from mental
illness or severe or chronic physical illness as above In addition, I confirm that I have found
that the applicant does not suffer from any mental or physical illness or disability, which
requires medication or which would not allow the applicant to @rry out full time strenuous
physical work in lsrael, including such as heavy lifting, working in the sun or in the rain or
cold etc.

Physician's name Signature

License No. Date l_t