Personal Medical Statement - The Hebrew University of Jerusalem

The Hebrew University of Jerusalem
The Robert H. Smith Faculty of Agriculture, Food & Environment
International School of Agricultural Sciences
Personal Medical Statement 2016
First and middle name (as it appears on your Chinese
passport):
Family name (as it appears on your Chinese
passport):
Instructions:
Please complete the application, print out and send by mail with the other documents in the application process.
Do not leave any blank spaces. Incomplete applications will not be considered. The Hebrew University reserves the
right to require the applicant to undergo a further medical examination before or during the period of studies.
If you answer "yes" to any question, please include dates in the field on the right and explain on a separate page.
1.
Have you had in the past or do you now have problems
related to:
Date
Heart (cardiovascular), lung and/or respiratory system
(Tuberculosis, asthma, tumor, etc.)
Yes
No
Stomach, intestines, liver, kidney (nephritis, stones, etc.)
Yes
No
Nervous system (convulsions, stroke, mental illness, stress-related
disorders, etc.)
Yes
No
Glandular system (such as goiter, diabetes, anemia)
Yes
No
Skin, muscles, bones, joints
Yes
No
Sensory organs (eyes, ears, etc.)
Yes
No
STD (sexually transmitted diseases), including HIV
Yes
No
2.
Has any member of your family had:
Date
Tuberculosis
Yes
No
Mental illness
Yes
No
Asthma
Yes
No
Epilepsy
Yes
No
Malaria
Yes
No
STD (sexually transmitted diseases), including HIV
Yes
No
DECLARATION
I, the undersigned, understand and agree that the University reserves the right to take any necessary measures in
connection with candidates who submit partial, incorrect and/or false information, and certify that all information
given here is full and correct. I waive my right to privacy regarding all medical information and documentation
relevant to processing my application to the study program.
Date (dd/mm/yy):
Applicant's Signature:
Noa Schwarzwald, Head of International Programs
International School for Agricultural, Robert H. Smith Faculty of Agriculture, Food & Environment, Herzl Street, POB 12, Rehovot, Israel 7610001
Email: noapl@savion.huji.ac.il
Tel: 972-8-9489996 Fax: 972-8-9470171
The Hebrew University of Jerusalem
The Robert H. Smith Faculty of Agriculture, Food & Environment
International School of Agricultural Sciences
Noa Schwarzwald, Head of International Programs
International School for Agricultural, Robert H. Smith Faculty of Agriculture, Food & Environment, Herzl Street, POB 12, Rehovot, Israel 7610001
Email: noapl@savion.huji.ac.il
Tel: 972-8-9489996 Fax: 972-8-9470171