iHC

^{Background medical information regarding all family members in advance of a proposed international assignment}

^Name(s):

^{Personal ID-number(s):}

^{Date of completion of this questionaire:}

^{1. Do you, or anyone accompanying you, have any illness or complaint, mental or physical, which makes you consult a doctor or hospital at regular or unregular intervals? � Yes � No If ”Yes”, see below.}

^{Please comment if appropriate:}

^{2. Do you, or anyone accompanying you, have any illness or complaint, mental or physical, which requires medication? � Yes � No If ”Yes”, see below.}

^{Please comment if appropriate:}

^{3. Do you, or anyone accompanying you, have any medical examinations or operations scheduled?}

^{� Yes � No If ”Yes”, see below.}

^{Please comment if appropriate:}

^{4. Do you, or anyone accompanying you, have any illness, mental or physical (apart from e.g. common colds), which has required hospital stay or other medical treatment during the last five years?}

^{� Yes � No If ”Yes”, see below.}

^{Please comment if appropriate:}

^{5. Do you, or anyone accompanying you, have any current symptoms that you think should be discussed with a medical doctor?}

^{� Yes � No If ”Yes”, see below.}

^{Please comment if appropriate:}

^{If answering YES to any of the questions above, it is important that you visit or contact, by phone, fax or e-mail, International Health Center, iHC, as soon as possible to discuss the implications upon the proposed international assignment. Please provide us with as much information as possible, e.g. old medical records etc., to facilitate the process.}

^{………………………………………………}

^{Signature of the person completing this form}

^{Kind regards}

^{International Health Center, Carlanderska sjukhemmet, S-412 55 Göteborg, Sweden, Phone +46 (0)31 187200, 818095, fax +46 (0)31 188010, E-mail contact@ihc.nu, Web www.ihc.nu}