FP 100 Health certificatePage1of8

SECTION I: INFORMATION ON THE PHYSICIAN
1 / a Are you the applicant’s ordinarily visited general practitioner?
b Are you acquaintedwith the applicant? / No Yes
 
  / If YES, since when?______(MM/YY)
IfNO, how has the identity been ascertained? ______
SECTION II: PHYSICIAN’S QUESTIONS TO THE APPLICANT WITH PATIENT RECORDS
1The patient is questioned regarding former and current illnesses, examinations, treatments, use of medicine, alcohol, tobacco and stimulants. Please enclose relevant patient records, e.g. letters from doctors, discharge letters, lab results.
2 Please note that the following information may not be disclosed to the insurance company/pension fund:
  • Information on current or former state of health of other persons, e.g. relatives.
  • Information on the result of genetic tests that have beencarried out to clarify the applicant’s future risk of incurring specific illnesses (predictive genetic tests).
  • Information on participation in and results of preventive examinations. However, the results of such examinations may be disclosed, if they show pertinent signs of illness, or if they pertain to illnesses that the applicant has previously had or that are already in outbreak.
3Please note the consequences for the patient, if the information is insufficient, cf. the provisions of the Danish Insurance Contracts Act (please see above).
1 / Does the applicant have, or has the applicant during the past [10] years had: / Please state: Diagnosis, symptom onset, time of diagnosis, course of diseaseand current symptoms.
a Infectious diseases (except ordinary colds), e.g. meningitis, rheumatic fever, tropical diseases, malaria, HIV/AIDS?
Please enclose supplementary patient records, including results of laboratory tests. / No Yes
 
b Benign or malignant tumors, e.g.cancer, precancerous lesions (dysplasia), leukemia and lymphoma, polyps, cysts and/or otherbenign tumors?
Please enclose supplementary patient records, including results of laboratory tests. / No Yes
  / Please state: Diagnosis, symptom onset, time of diagnosis, course of diseaseand current symptoms.
c Blood disorders, e.g.anemia, bone marrow diseases, coagulation and immunological defects and og spleen diseases?
Please enclose supplementary patient records, including results of laboratory tests. / No Yes
  / Please state: Diagnosis, symptom onset, time of diagnosis, course of diseaseand current symptoms.
d Metabolic disorders, e.g.diabetes (includinghyperglycemiaand gestational diabetes), goitreormetabolic irregularities and high blood cholesterol?
Please note: in case of metabolic disorders (including dyslipidemia), please state control values and treatment, if any.
Please enclose supplementary patient records, including results of laboratory tests. / No Yes
  / Please state: Diagnosis, symptom onset, time of diagnosis, course of diseaseand current symptoms.
e Mental illnesses, e.g. depression, nervousness, anxiety, stress, crisis reaction etc.?
Have there been any suicidaltendencies or poisoning incidents?
Please enclose supplementary patient records, including results of laboratory tests. / No Yes
 
  / Please state: Diagnosis, symptom onset, time of diagnosis, course of diseaseand current symptoms.
f Diseases of the nervous system (including eye and ear diseases)e.g.headacheormigraine, dizziness, epilepsy, cramps or fainting, paralyses or musculoskeletal disorders, brain haemorrhage, blood clots, sensory disturbances, including multiple sclerosis?
Please enclose supplementary patient records, including results of laboratory tests. / No Yes
  / Please state: Diagnosis, symptom onset, time of diagnosis, course of diseaseand current symptoms.
g Heart,circulationorvascular diseases, e.g.hypertension, angina pectoris, palpitationor irregular heart rate, blood clots, heart or heart valve defects, varicose veins or venitis, blood clots in legs, claudicatio intermittens?
Please note: in case of hypertension, please state initial blood pressure level, current treatment and period of treatment.
Please enclose supplementary patient records, including results of laboratory tests. / No Yes
  / Please state: Diagnosis, symptom onset, time of diagnosis, course of diseaseand current symptoms.
h Lung orrespiratory diseases, e.g. asthma, hay fever or allergy,bronchitis, Chronic Obstructive Pulmonary Disease (COPD), tuberculosis, lung blood clot, lung infections, silicosis, emphysemaandsarcoidosis?
Please enclose supplementary patient records, including results of laboratory tests. / No Yes
  / Please state: Diagnosis, symptom onset, time of diagnosis, course of diseaseand current symptoms.
i Digestive diseases (stomach, intestine, liver, gallandpancreas), e.g.ulcer (ulcus) or
haemorrhages, gastritis, gullet discomfort or reflux, indigestion (irritable bowel, coeliac disease or allergy), inflammation of the large or small intestine,intestinal malrotation, polyps, jaundiceorhepatitis, gallstone, fatty liver (steatosis), affectedliver count (blood samples), pancreatitis?
Please enclose supplementary patient records, including results of laboratory tests. / No Yes
  / Please state: Diagnosis, symptom onset, time of diagnosis, course of diseaseand current symptoms.
j Skin diseases, e.g.eczema (incl. allergy), skin cancer, psoriasis, inflammation (incl. boils), blister rashandvenereal disease?
Please enclose supplementary patient records, including results of laboratory tests(incl.histology results). / No Yes
  / Please state: Diagnosis, symptom onset, time of diagnosis, course of diseaseand current symptoms.
k Diseases in or discomfort in neck, back or lower back, e.g.infiltrations, sciatica, herniated disc, lumbago, whiplash, diseases of the spine, spine curvature?
Please enclose supplementary patient records, including results of laboratory tests. / No Yes
  / Please state: Diagnosis, symptom onset, time of diagnosis, course of diseaseand current symptoms.
l Diseases in joints, sinews, bone and connective tissue, e.g.sinew and ligament injuries, osteoarthritis, arthritis (rheumatologic diseases), fibromyalgia, osteoporosis, hypermobilityandsymphysis pubis dysfunction?
Please enclose supplementary patient records, including results of laboratory tests. / No Yes
  / Please state: Diagnosis, symptom onset, time of diagnosis, course of diseaseand current symptoms.
m Kidney and urinary diseases andgynaecologicaldiseases (includingpregnancy complications), e.g.nephritis or cystitis, kidney or bladder stones, blood, protein orbacteria in the urine, removal of kidney, deformities or cysts, femalegynaecological problemsandmaleurinary problems (incl. prostate)?
Please enclose supplementary patient records, including results of laboratory tests. / No Yes
  / Please state: Diagnosis, symptom onset, time of diagnosis, course of diseaseand current symptoms.
n Other diseases besides the above mentioned, except uncomplicated childhood illnesses, ordinary short-term and non-recurrent infectious diseases and uncomplicated cosmetic treatments?
Please enclose supplementary patient records, including results of laboratory tests. / No Yes
  / Please state: Diagnosis, symptom onset, time of diagnosis, course of diseaseand current symptoms.
2 / Has the applicant been injured within the last [10]years?
If YES, has it resulted in permanent injury?
Please enclose supplementary patient records, including results of laboratory tests. / No Yes
 
  / If YES: when?______
MM/YY
Nature of the injury?______
If YES: which symptoms? Degree of permanent injury?______
3 / Has the applicant had any long-term absence due to illness/inability to work (more than one month) within the last [10] years? / No Yes
  / If YES:
Which periods?______
MM/YY
For what reason?______
4 / Apart from the above, has the applicant received long-term medicinal treatment (more than one month) or recurring medicinal treatment, including treatment with sedatives or pain-relieving medication within the last [10]years? / No Yes
  / IfYES:
For what reason?______
During which periods?______
MM/YY
Current? NoYes
5 / Does the applicant, or has the applicant within the last [10] years used psychedelic drugs (e.g. heroin, speed, cocaine, ecstasy and LSD), hash, organic solvents, anabolic substances or other stimulants or sedatives? / No Yes
  / If YES:
During what periods(MM/YY)? ______
Currently? NoYes
Which compounds/drugs?______
Any permanent injury? NoYesWhich?______
______
6 / a Does the applicant drink beer, wine, fortified wine or spirits? / No Yes
  / IfYES:
Average number of units per week?_____
b Has the applicant within the last [10] years had a large intake of beer, wine, fortified wine or spirits? / No Yes
  / IfYES:
Average number of units per week?_____
During what periods?______
MM/YY
c Has the applicant within the last [10] years received treatment or counselling for excessive use of beer, wine, fortified wine or spirits? / No Yes
  / IfYES:
During what periods?______
MM/YY
Currently? NoYes
What kind of treatment/counselling?______
With which effect?______
______
7 / a Does the applicant smoke? / No Yes
  / IfYES:
Daily consumption?______
(number of cigarettes, cigars, pipe fillings)
b Has the applicant been smoking within the last [10] years? / No Yes
  / IfYES:
During what periods(MM/YY)?______
Daily consumption?______
(number of cigarettes, cigars, pipe fillings)
I have read the replies and herebystate that the above information is in accordance with the truth and that nothing has been concealed. I am aware that the insurance may be terminated or that coverage may be reduced if the information is incomplete, incorrect, or in case of non-disclosure.
______
Date Insurance Applicant’s signature CPR-no.
SectionIII: PHYSICIAN’S EXAMINATION
1 / Applicant’s height and weight / Height (without shoes):______cm.
Weight (without outer garments):______kg.
2 / Abnormalities detected at:
a Head, mouth cavity, pharynx, throat? / NO YES
  / If YES, please describe.
b Eyes, incl. eyesightwith best correction? /   / Visual acuity (w. corr.) R.:______L.:______
c Ears, incl. hearing with best correction?
Hearing can be measured by talking in normal voice and whisper from a distance of 4 metres /   / Hearing(w. corr.):______
d Chest, incl. deformitiesand mobility /  
e Lungs, incl. stethoscope?
In case of lung disease, including asthma andsymptoms of bronchitis, please perform 3 peakflow measurements(if necessarya spirometry). /   / Peakflow rating (PFT) in case of lung disease:
Rating1: / Rating2: / Rating3:
f Heart and blood vessels, incl. stethoscopy, pulseand blood pressure?
The blood pressure measurements must be taken three times with at least one minute apart after a 5 minute rest.
In case of discovery of hypertension:
Has further diagnosing/treatment been initiated? /  
  / Pulse Blood pressure
Rating1: / Rating2: / Rating 3:
Rhythm:
______/ Systolic
Frequency:
______/ Diastolic
Which?______
g Abdomen, e.g.distension, organ tumor, soreness, cicatrix?
No gynecological or rectal examination is required. /  
h Vertebral column, incl. abnormal curvatures? /  
i Arms, legs and joints, e.g.varicose veins, oedemas, peripheral pulse, indications of current or ended venitis, muscular dystrophy? /  
j Skin and lymph nodes (neck, armpit, groin)? /  
k External genitalia, incl. palpation of breasts? /  
l Examination of the nervous system, e.g. paralysis, tremors, reflexes, sensory disturbances? /  
3 / Stix examination of urine.
In case of newly discovered
positive results:
Has further diagnosing/treatment been initiated? / NO YES
  / Protein / Sugar / Blood
In case of a positive reaction, please indicate below the result of an immediate follow-up examination.
Follow-up date:______
Result:
Protein / Sugar / Blood
If YES:
Which?______
4 / Does appearance or behaviour in any way indicate frailty or illnessincluding mental illness? / NO YES
  / IfYES:
How?______
______
5 / In your opinion, is the applicant:
Healthy (without symptoms)?
Fully able to work? / YESNO
 
  / If NO:
Why not?______
Why not?______
This certificate has been filled in by me in accordance with the medical documents at hand, my knowledge of the patient, my questions to the patient and my examinationof the patient:
______
Date Physician signature
Exact address (stamp): / Please send the certificate in a sealed envelope marked “HEALTH CERTIFICATE” to:

The physician will be paid upon receipt of an invoice cf. the agreement between The Danish Insurance Association and the Danish Medical Association on medical certificates and health information etc. 04.01.01.04