Bundesvertretung der Medizinstudierenden in Deutschland e.V.

Health Form

Health Form

Please have this form completed by your Physician/General Practitioner or University

Medical Centre.
ONLY results from tests taken three months prior to submission of the application form will
be accepted.
ALL sections of the form must be completed in full. Incomplete documentation will not be
accepted.

Jhara Melany Torres Wong 07/10/1996

Hereby I certify that I examined [name] , born [birth date] ,
and found that she/he is in good physical and mental health and protected against the infectious diseases
listed below by means of vaccination or proof of sufficient antibody count.
Tick if applicable. Please make sure to attach laboratory results.

COVID vaccination Date vaccine (e.g. Pfizer)

21/10/2021 Pfizer
 1st Dose _______________ __________________
 2nd Dose 19/11/2021
_______________ Pfizer
__________________
 3rd Dose 20/02/2022
_______________ Pfizer
__________________
 optional: Booster shot: _______________ __________________
if only 2 shots were received:
 prior infection proven with PCR
Please attach a laboratory proof.

Hepatitis A Date:
 1st Dose 17/05/2021
 2nd Dose 25/11/2021
OR
 serological proof of immunity

13/12/2022

Place, date Signature Stamp (name, address)

Version Okt 2022

bvmd.de 1/3 buero@bvmd.de

Bundesvertretung der Medizinstudierenden in Deutschland e.V.
Health Form

Hepatitis B Date:
 1st Dose 07/12/1996
07/02/1997
 2nd Dose
07/04/1997
 3rd Dose
AND to prove immunity
January 2021:
 Anti-HBs Result: 264
_________IU/L 23/22/2022 04/01/21 HbS-Ag negative
02/01/21 Anti-HBs 521 IU/L
Note: it should be > 10 mIU/ml (100 IU/L) and is not the same as HbS-Ag

Hepatits C Date:
 Anti-HCV-antibodies 23/22/2022

HIV Date:
23/22/2022
 Anti-HIV-antibodies

Measles/Mumps/Rubrella (MMR) – Vaccination Date:

1st Dose
07/10/1997

 2nd Dose 07/05/1998
Extra shot (Measles/Rubrella) 04/01/2021
Varicella Date:
 1st Dose
 2nd Dose
 OR Past infection 2010

 OR Vaccination titer/serology

Pertussis Vaccination Date:

 last vaccination was within the last 10 years 03/09/2021

Tetanus Vaccination Date:

 Full immunization 03/09/2021

13/12/2022
Place, date 13/12/2022 Signature Stamp (name, address)

Version Okt 2022

bvmd.de 2/3 buero@bvmd.de

Bundesvertretung der Medizinstudierenden in Deutschland e.V.
Health Form

Diphteria Vaccination Date:

 Full immunization 03/09/2021

Poliomyelitis Date:
 Full immunization 03/09/2021

Pulmonary Tuberculosis [one is sufficient] Date:

 BCG Scar [yes/no] 07/10/1996

 Mantoux tuberculin skin test [positive/negative]

 Chest X-Ray

Influenza vaccination [optional!] Date:

 Vaccinated

13/12/2022
Place, date Signature Stamp (name, address)

Version Okt 2022

bvmd.de 3/3 buero@bvmd.de