The Health Declaration Form is a crucial document used in Belgium for collecting and documenting an individual's health information in various contexts. It is designed to comply with stringent EU data protection requirements (GDPR) and specific Belgian healthcare and privacy regulations. The form is commonly required for employment screening, insurance applications, educational enrollment, travel clearance, or general health status documentation. It typically includes sections for personal information, current health status, medical history, and necessary consent declarations. The document must incorporate specific privacy notices and data processing information as mandated by Belgian law, particularly the Belgian Privacy Act of 2018 and the Patient Rights Act of 2002. Given the sensitive nature of health data, the form includes robust data protection measures and clear statements about information usage and storage.
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1. Personal Information: Basic identification details including full name, date of birth, national registration number, and contact information
2. Declaration Purpose: Clear statement of why the health declaration is being made (e.g., employment, insurance, travel)
3. Current Health Status: Section for declaring present health conditions, medications, and ongoing treatments
4. Medical History: Details of past significant medical conditions, surgeries, and treatments
5. Family Medical History: Relevant hereditary conditions and family health background
6. Privacy Notice: GDPR-compliant statement about how the health data will be processed, stored, and protected
7. Consent Statement: Express consent for data processing and verification of provided information
8. Declaration of Truth: Statement confirming all provided information is true and complete
9. Signature Block: Space for signature, date, and place of signing
1. COVID-19 Status: Optional section for COVID-19 vaccination status and recent exposure - include when required by current health regulations
2. Occupational Health Specific: Additional questions related to work capability and specific job requirements - include for employment-related declarations
3. Travel Health Declaration: Specific health questions related to travel and infectious diseases - include for travel-related declarations
4. Insurance-Specific Questions: Additional health questions required by insurers - include when form is for insurance purposes
5. Disability Status: Declaration of any disabilities or special needs - include when relevant for accommodation purposes
1. Medical Conditions List: Comprehensive checklist of common medical conditions for reference
2. Privacy Policy: Detailed explanation of data protection measures and privacy rights
3. Supporting Documents Checklist: List of required medical certificates or test results that need to be attached
4. Emergency Contact Form: Additional form for emergency contact information
5. Medical Professional Verification: Optional form for doctor's verification of declared health conditions
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