Medical Screening Questionnaire

Full Names:
Date of Birth:
Company:
Position:

List the countries you have travelled to in the last month:

In the past 3 weeks have you experienced any of the following?

YES NO
Abdominal Pain
Breathing Difficulty
Chills
Cough
Diarrhea
Fatigue/Malaise/Weakness (new)
Fever
Nausea
Nasal Discharge
Rash
Sore Throat
Shortness of Breath
Other:
If YES please give more details:

Do you suffer / have any severe allergies? Please specify if “YES”

YES NO
Do you have any health or medical issues that the Doctor should be aware of?
Are you presently taking any prescribed or over the counter medication?
Are you allergic to anything?
If YES please give more details:

I, [__________________], declare that the information provided in this form is true and accurate to
the best of my knowledge.

I am not aware of any medical conditions that I have not disclosed on this form.

I have read and understand the above statements.

Signature: ______________________
[Date]

FG-Gold Form – Medical Screening Questionnaire

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