Medical Declaration Form Template for Denmark

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Medical Declaration Form

Document background

The Medical Declaration Form is a fundamental document used in the Danish healthcare system to collect and record essential medical information from individuals. This form is typically required in various situations, including new patient registration, pre-treatment assessments, insurance applications, employment medical screenings, and specific medical procedures. The document must comply with the Danish Health Act (Sundhedsloven), the Danish Data Protection Act, and EU GDPR requirements, particularly regarding the handling of sensitive personal data. The form includes comprehensive sections covering personal information, current health status, medical history, medications, and necessary consents. It serves as a crucial tool for healthcare providers, insurance companies, and employers to make informed decisions while ensuring proper documentation and protection of medical information.

Suggested Sections

1. Personal Information: Patient's full name, CPR number (Danish personal ID), contact details, and emergency contact information

2. Current Health Status Declaration: Patient's current health conditions, symptoms, and ongoing treatments

3. Medical History: Previous illnesses, surgeries, hospitalizations, and chronic conditions

4. Medication Information: Current medications, dosages, and any known drug allergies

5. Family Medical History: Relevant hereditary conditions and significant family health issues

6. Lifestyle Factors: Smoking status, alcohol consumption, exercise habits, and other relevant lifestyle information

7. Privacy Notice: GDPR-compliant information about how medical data will be processed and stored

8. Declaration and Consent: Patient's confirmation of information accuracy and consent for data processing

9. Healthcare Provider Details: Information about the medical professional receiving/processing the declaration

Optional Sections

1. Pregnancy Status: For female patients of childbearing age, when relevant for treatment or diagnosis

2. Occupational Health Information: When the form is being used for work-related health assessments

3. Travel History: When relevant for infectious disease screening or epidemiological purposes

4. Vaccination History: When needed for specific medical or occupational requirements

5. Mental Health Status: When mental health assessment is relevant to the purpose of the declaration

6. Specialized Medical Questions: Additional questions specific to certain medical specialties or conditions

Suggested Schedules

1. Appendix A - Detailed Medication List: Comprehensive list of current and recent medications with dosages

2. Appendix B - Previous Medical Records: Relevant prior medical documentation or test results

3. Appendix C - Specialty Questionnaires: Additional detailed questions for specific medical conditions or specialties

4. Appendix D - Consent Forms: Additional specific consent forms for particular treatments or data sharing

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