PERSONAL HEALTH STATEMENT

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PERSONAL HEALTH STATEMENT Health declaration (HD) is information submitted by the person regarding their medical state based on a corresponding questionnaire. HD is accessible to the patient s physicians or members of the medical committees of the Estonian Ministry of Defence, giving a quick overview of the patients health or condition and background information for making a more exact treatment or other health related decision. HD is usually filled out electronically in the patient portal, in exceptional cases on paper for objective reasons. HD is an obligatory prerequisite for obtaining health certificate or passing medical committee of Ministry of Defence. If the patient wants to answer only certain question which are mandatory in regards to the field of use of the HD, then the HD must be filled out on paper. All of the questions in the electronic HD are mandatory. The patient verifies the HD with his or her signature and it is valid for 30 days in case of health certificate and 3 months in case of medical committees of the Ministry of Defence. HD filled out on paper is only valid for one doctors appointment and the next time the patient must fill out or insert all the information fields on the HD again. Additionally, HD filled out on paper (unlike electronically filled out HD in the patient portal) is not accessible later through the patient portal. Personal identity code Name 1. LIFESTYLE Do you drink alcohol? No Yes How many units of alcohol in a week? of wine (12% alcohol) or 250 ml of beer (5,2% alcohol) units (1 unit = 40 ml of spirits (40% alcohol by volume) or 120 ml Do you smoke? No Yes How many cigarettes a day? How many years have you been smoking? If you have quit smoking, when did you quit? Do you use drugs / psychotropic substances? No Yes Please, specify how often Are you taking any medication that in your opinion could affect your coordination or concentration ability? No Yes 2. WORKING ENVIRONMENT Have you had any work restrictions recommended by a physician or licenced health care professional? No Yes If so, please specify Do you currently have or have had any health problems that are related to your work or working environment? No Yes 3. ALLERGIES None Drug allergy (please specify) Food allergy (please specify) Pollen allergy (please specify) Domestic pets allergy (please specify)

Other allergies (please specify) 4. MENTAL HEALTH No complaints Depression Schizophrenia Fear of working alone Fear of closed spaces Fear of heights 5. NERVOUS SYSTEM No complaints Fainting spells (syncope) Convulsions (epilepsy) Balance disorders (incl. Meniere s disease) Cerebral infarction or stroke Seasickness 6. EYES AND VISION No complaints Short-sightedness Visual field restriction when looking up and down or to the sides? Double vision Colour vision disorders 7. EAR, NOSE, THROAT No complaints Hearing loss Allergic rhinitis Chronic sinusitis of frontal or maxillary sinuses Nasal obstruction Frequent (more than 4x a year) throat problems

8. RESPIRATORY SYSTEM No complaints Asthma Chronic obstructive pulmonary disease (COPD) Sleep apnoea 9. METABOLIC DISORDERS (INCL THYROID DISEASE) No complaints Diabetes 10. CARDIOVASCULAR CONDITION No complaints Chest pain related to physical activity High blood pressure I have had a heart attack Irregular heartbeat (arrhythmia) I have had coronary angioplasty (coronary stent procedure) I have a pacemaker I have had a heart surgery 11. BONES, JOINTS AND MUSCLES No complaints Joint stiffness Partial or complete paralysis of limb (please specify) Missing of a complete or part of a limb (please specify) Trembling hands Joint pain Neck pain Shoulder pain Lower back pain

12. INFECTIOUS DISEASES I have not had any to my knowledge Tuberculosis Viral hepatitis HIV carrier AIDS 13. OTHER CHRONIC DISEASES, CONDITIONS OR SYMPTOMS NOT DESCRIBED ABOVE Disease / condition / symptom (please specify, when and what) None 14. TREATMENT UP TO NOW Have you been hospitalized or visited a doctor abroad? Please specify why, when and where Are you taking regularly any medication (incl. contraceptives)? If so, please list Have you been hospitalized? Have you had surgery? Please specify why and when 15. TRAUMAS None Bone fractures (please specify, when and what) Other significant injuries (please specify, when and what) 16. ARE YOU PREGNANT? No Yes 17. SKIN DISORDERS (PLEASE SPECIFY, WHEN AND WHAT) No Yes

18. DIGESTIVE ORGANS No complaints Liver disease Gallstones Gastric and duodenal ulcers Ulcerative colitis or Crohn s disease 19. UROGENITAL SYSTEM No complaints Kidney diseases Kidney stones Renal insufficiency 20. BLOOD PROBLEMS No complaints Blood disease Anaemia (iron-deficiency) 21. I USE THE FOLLOWING MEDICAL DEVICES / SUPPORT DEVICES None Glasses Contact lenses Hearing aid / cochlear implant Arm prosthesis Leg prosthesis Mobility support device Continuous positive airway pressure (CPAP) device or non-invasive ventilation device Mandibular advancement splint for treatment of sleep apnoea Other support device (please specify, what) 22. SLEEP Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? No Yes Do you often feel tired, fatigued, or sleepy during daytime? No Yes Has anyone observed you stop breathing during your sleep? No Yes

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