MEDICAL FORM USM 2025

Medical Form EN

Personal Data Protection Policy: https://www.grupohpa.com/en/hpa-heath-group/personal-data-protection-policy/

PERSONAL DATA

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* 1. Please enter your date of birth

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* 2. Nationality

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* 3. Name

MEDICAL FORM

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* 4. Describe the medication you usually take:

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* 5. Diabetes?

Yes

No

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* 6. If you have Allergy(s) (Drugs, Food and/or other(s)) please describe:

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* 7. Respiratory disease?

Yes

No

If yes, which one?

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* 8. Epilepsy?

Yes

No

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* 9. High Blood Pressure?

Yes

No

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* 10. Heart Disease?

Yes

No

If yes, which one?

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* 11. Have you had any major injuries since 2025?

Yes

No