<p> MEDICAL REPORT / ADEVERINTA MEDICALA </p><p>To be completed by the “family physician” or a physician in a clinic in which the applicant has received care for a minimum of 5 years. Please fill in with block letters and well legibly. Formularul poate fi completat doar de medical de familie sau de medicul din clinica/spitalul unde aplicantul primeste ingrijiri medicale de cel putin 5 ani. Completati cu majuscule.</p><p>Name of the applicant/Numele aplicantului:</p><p>Name of Doctor or Clinic/Numele medicului sau clinicii:</p><p>Telephone day/Telefon fix Mobile/Mobil: Address/Adresa:</p><p>Ti Tick the appropriate box if the applicant suffers or ever suffered from the below/A suferit sau sufera aplicantul de urmatoarele:</p><p>□ □ tuberculosis/tuberculoza □ migraine/migrene □ diabetes/diabet □ □ asthma/astm □ rheumatic fever/febra reumatica □ hepatitis/hepatita (A,B,C) □ □ depression/depresie □ anorexia/anorexie □ bulimia □ □ HIV □ epilepsy/epilepsie □ malaria/malarie □ RPR/Syphilis □ A (H1N1)</p><p>If you have answered YES to any of the above give details including dates as applicable/Daca ati raspuns cu DA la vreunul din cele sus enumarate, va rugam sa detaliati (inclusiv data):</p><p>Does the applicant suffer from any allergies?/Sufera aplicantul de alergii din cele jos mentionate:</p><p>□ □ penicillin/penicilina □ other drugs/alte medicamente □ animals/animale □ □ food addititves/aditivi □ insect stings/intepaturi de insecte □ other/alte If you have answered YES to any of the above give full details / Daca ati raspuns cu DA la vreunul din cele sus enumarate, va rugam sa detaliati:</p><p>Yes/DA NO/NU</p><p>Is her/his physical activity restricted in any way ?/Activitatea fizica este restrictionata in vreun fel ?</p><p>Is the applicant currently taking any medications ?/Este aplicantul in prezent sub tratament medical ?</p><p>Does the applicant have any cronic or recurring illness ?/Sufera aplicantul de boli cronice ?</p><p>If you have answered YES to any of the above give full details / Daca ati raspuns cu DA la vreunul din cele sus enumarate, va rugam sa detaliati:</p><p>How would you describe the applicant’s general state of health?/Cum ati descrie starea generala de sanatate a a aplicantului: □ □ excellent/excelent □ good/bun □ satisfactory/satisfacator □ poor/slaba</p><p>Signature&Stamp/Semnatura si stampila ______Date/Data: ______</p>