Medical Self Declaration Form Template for Switzerland

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Key Requirements PROMPT example:

Medical Self Declaration Form

"I need a Medical Self Declaration Form for a private Swiss international school, to be used for student enrollment starting in January 2025, with particular emphasis on vaccination records and allergy information, including provisions for sharing information with school medical staff."

Document background

The Medical Self Declaration Form is a critical document in the Swiss healthcare and institutional landscape, designed to collect accurate medical information from individuals while ensuring compliance with Swiss data protection and healthcare regulations. This document is typically required when joining new healthcare providers, applying for insurance coverage, beginning employment, participating in sporting activities, or enrolling in educational institutions within Switzerland. The form must comply with the Federal Act on Data Protection (FADP) and relevant cantonal health laws, particularly regarding the handling of sensitive personal data. It includes comprehensive sections covering personal information, medical history, current health status, and necessary declarations, with provisions for multilingual presentation as required in Switzerland's multi-lingual environment.

Suggested Sections

1. Personal Information: Declarant's full name, date of birth, address, contact details, and identification numbers (including Swiss health insurance number if applicable)

2. Purpose Declaration: Clear statement of why the medical self-declaration is being made and how the information will be used

3. Data Protection Notice: Information about how personal data will be processed, stored, and protected in accordance with FADP

4. Current Health Status: Declaration of current general health condition and any ongoing medical treatments

5. Medical History: Details of significant past medical conditions, surgeries, and treatments

6. Family Medical History: Relevant hereditary conditions and significant family medical history

7. Medication Declaration: List of current medications, including prescription, over-the-counter drugs, and supplements

8. Lifestyle Factors: Information about relevant lifestyle factors such as smoking, alcohol consumption, and physical activity

9. Declaration of Truth: Statement confirming that all provided information is true and complete

10. Signature Section: Date, place, and signature fields for the declarant and witness if required

Optional Sections

1. Emergency Contact Information: Contact details for emergency situations - required for forms used in medical or institutional settings

2. Specific Condition Declaration: Detailed questions about specific medical conditions - included when the form is for a particular medical purpose or institution

3. Insurance Information: Details of health insurance coverage - required when the form is for insurance or healthcare provider purposes

4. Travel Health Declaration: Recent travel history and related health factors - included when the form is for travel-related purposes or during public health emergencies

5. Vaccination Record: Documentation of relevant vaccinations - required for specific institutional or travel purposes

6. Consent for Information Sharing: Specific permissions for sharing medical information with named parties - included when information sharing is needed

Suggested Schedules

1. Medical Conditions Checklist: Detailed checklist of common medical conditions for the declarant to mark yes/no

2. Medication List Template: Structured template for listing current medications, dosages, and frequencies

3. Information Sharing Consent Form: Detailed form specifying exactly which information can be shared and with whom

4. Privacy Policy: Detailed explanation of how the medical information will be handled and protected

5. Instructions for Completion: Detailed guidelines on how to complete the form accurately

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

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Medical Director

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Let's create your Medical Self Declaration Form

Authors

Alex Denne

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