Declaration of Health Condition
*Course Name and Dates: Eliminating Rural Poverty - The Israeli Development Experience (June 28 – July 9 2009)Eliminating Rural Poverty - The Israeli Development Experience (November 30 - December 10 2009) *First Name: Middle Name: *Surname: *Date of Birth (dd/mm/yyyy): 12345678910111213141516171819202122232425262728293031 123456789101112 194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990 *Gender: MaleFemale *e-mail address Have you / do you suffer from the following: *Heart (Cardiovascular) No Yes If yes, please specify *Hypertension No Yes If yes, please specify *Diabetes No Yes If yes, please specify *Epilepsy No Yes If yes, please specify *Mental Disorders No Yes If yes, please specify *Tuberculosis No Yes If yes, please specify *Bronchial Asthma No Yes If yes, please specify *Visual Disorders No Yes If yes, please specify *Malaria No Yes If yes, please specify *Sexually - Transmitted Diseases ( Including AIDS) No Yes If yes, please specify *Malignant Disorders ( or other tumors) No Yes If yes, please specify *Internal Bleeding No Yes If yes, please specify *Have you undergone surgical procedures? No Yes If yes, please specify *Have you undergone medical exams during this year? No Yes If yes, please specify *Are you currently using any medications? No Yes If yes, please specify Are you currently pregnant? If yes, what month? No Yes If yes, please specify