MEDICAL FORM USM 2024

Medical Form EN

Personal Data Protection Policy: https://www.grupohpa.com/en/hpa-heath-group/personal-data-protection-policy/

PERSONAL DATA

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1. Please enter your date of birth

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2. Nationality (Obrigatório.)

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3. Name (Obrigatório.)

MEDICAL FORM

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4. Describe the medication you usually take:

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5. Diabetes? (Obrigatório.)

Yes

No

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6. If you have Allergy(s) (Drugs, Food and/or other(s)) please describe:

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7. Respiratory disease? (Obrigatório.)

Yes

No

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8. Epilepsy? (Obrigatório.)

Yes

No

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9. High Blood Pressure? (Obrigatório.)

Yes

No

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10. Heart Disease? (Obrigatório.)

Yes

No

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11. Have you had any major injuries since 2023? (Obrigatório.)

Yes

No