International health insurance coverage by linzhengnd

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									                                                                                              Health Form

                                    Área de Relaciones Internacionales



                                           Para completar por el Alumno de Intercambio

4. Health Form

Your full Name:
Date of Birth (dd/mm/yy):                       Gender:          male               female
Home University:


You must provide proof of your health insurance company (included in your application form).
You should purchase insurance in your country.

Health Insurance Company:
Insurance Policy Nº:                  Emergency  Nº :


In case of emergency, please contact:

Name:
Relationship:
Home  number (country code+ region code + number):
Work  number (country code+ region code + number):
Cel  number:
E-mail:




        Maestro Marcelo López esq. Av. Cruz Roja Argentina - (X5016ZAA) Ciudad Universitaria- Córdoba – Argentina
           Teléfono: +54-(0)351-4684006/ 4684215 - Fax: (0)351-4681823 - internacionales@sae.frc.utn.edu.ar
                                                                                               Health Form

                                      Área de Relaciones Internacionales


Medical Information

Blood type:           (ABO system)                   (Rh system)

Allergies:       No            Yes:

Medical history (please circle any that apply):

  Diabetes                                                                                 Yes           No
  Hypertension                                                                             Yes           No
  Cardiovascular disease                                                                   Yes           No
  Depression                                                                               Yes           No
  Eating disorder (anorexia, bulimia, overweight)                                          Yes           No
  Chronic disease:                                                                         Yes           No
  Are you under medical treatment *                                                        Yes           No
  Epilepsy or other neurological disorder                                                  Yes           No

*In this case, include medical prescription and type of medicine you need to take.


Please include any information regarding your Health that you feel is relevant for us to know:




         Maestro Marcelo López esq. Av. Cruz Roja Argentina - (X5016ZAA) Ciudad Universitaria- Córdoba – Argentina
            Teléfono: +54-(0)351-4684006/ 4684215 - Fax: (0)351-4681823 - internacionales@sae.frc.utn.edu.ar

								
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