2
ANNEX I
MEDICAL DECLARATION
[to be filled by the involved person]
Do you suffer from or have you ever suffered from, had symptoms of, been examined for or been
treated for any of the following ailments, or anything related to them? Consider the examples as
help - they do not cover all conditions. Any other symptoms or ailments must also be stated, and a
clarification and further details should be written on the last page.
Diabetes, metabolic diseases, respiratory diseases,
gastrointestinal diseases, and diseases of the
musculoskeletal system
If yes; what and when:
What was the outcome of the treatment?
Is the treatment ongoing, completed or recurrent?
Cardiac and circulatory diseases
Blood clots, pain/tightness in the chest, high blood
pressure, varicose veins, phlebitis, swollen ankles,
heart rhythm disorders, pacemaker, elevated
cholesterol. Other cardiovascular disorders
If yes; what and when:
What was the outcome of the treatment?
Is the treatment ongoing, completed or recurrent?
Cancer, other tumors/growths, immune system-
related disorders
Any type of cancer or cancer precursor/suspected
cancer. Polyps in the bowel, benign
tumors/growths
If yes; what and when:
What was the outcome of the treatment?
Is the treatment ongoing, completed or recurrent?
Neurological disorders
Epilepsy, migraine and headache disorders,
multiple sclerosis, stroke, alcohol-related disorders,
dementia, brain injury, infections and genetic
diseases, Parkinson’s disease, chronic pain and
other neurological
If yes; what and when:
What was the outcome of the treatment ?
Is the treatment ongoing, completed or recurrent?
Psychiatric and behavioral disorders
Nervousness, anxiety, psychosis, depression,
mania, insomnia, or disorders related to addiction
to alcohol or drugs, or other addictions. Dementia.
Developmental and behavioral disorders,
compulsive behaviors (ADHD, OCD, etc.). Other
psychiatric disorders and symptoms?
If yes; what and when:
What was the outcome of the treatment ?
Is the treatment ongoing, completed or recurrent?