__________________ Dept, year ____________________

Change status ___________________

Dormitory ____________________
_____________________________________________________________________________________________
Please, fill out all the lines this form and submit it to the AUCA Medical Office
together with original medical documents mentioned on the Page 4.

Student’s Health Background Form

I. Personal data
*Please, write data exactly as it appears on your personal ID (passport)

First name: _______________________________________

Last name: _______________________________________

Patronymic: ______________________________________ Attach photo 3x4

Date of birth: _____________________________________

Citizenship: ______________________________________

Personal ID (passport) #: ___________________________ Sex: Male / Female

Mobile phone: ____________________________________

E-mail: _________________________________________

Academic program (underline):

NGA Undergraduate Graduate Exchange student Visiting Student

Department: _____________________________________________

Contact person

Please write the contact information about a family member or tutor, who should be contacted in an
emergency situation:

First name, last name: ______________________________________________________________

Relation to student: _______________________________________________________________

Phone (including codes of country and city): ____________________________________________

E-mail: _________________________________________________________________________

Additional contact information (another family member / close relative):

First name, last name: ______________________________________________________________

Relation to student: _______________________________________________________________
Phone (including codes of country and city): ____________________________________________
 II. Medical information
All medical information is in strict confidence

a. Immunization records ___________________________

Submit information about immunization (according analogous form #063 in Kyrgyz Republic). Mark
Yes/No/I don’t know1

1 Measles Yes No I don’t know

2 Parotitis (mumps) Yes No I don’t know

3 Rubella Yes No I don’t know

4 Viral hepatitis B Yes No I don’t know

5 Pertussis Yes No I don’t know

6 Diphtheria Yes No I don’t know

7 Tetanus Yes No I don’t know

b. Indicate the health issues that affect you

Allergy to medications (write what medicaments cause allergy

1 Yes No I don’t know
and reactions in detail in the “Notes” section)
Allergy for stings of insect or some food (write causes and
2 Yes No I don’t know
reactions in detail in section “Notes”)
3 Pollinosis, nettle rash, seasonal allergies Yes No I don’t know

4 Asthma Yes No I don’t know

5 Vision loss, hearing loss (blindness, deafness) Yes No I don’t know

6 High arterial pressure Yes No I don’t know

7 Migraine, headaches Yes No I don’t know

8 Brain concussion Yes No I don’t know

9 Epilepsy Yes No I don’t know

10 Depression Yes No I don’t know

11 Psychological illness (write in details in section “Notes”) Yes No I don’t know

12 Drug abuse Yes No I don’t know

Cardiac (heart) diseases (write in details in section “Notes” –

13 Yes No I don’t know
name, date of disease)
14 Diabetes Yes No I don’t know

15 Thyroid gland diseases or other endocrine diseases Yes No I don’t know

16 Hepatitis A Yes No I don’t know

17 Hepatitis B Yes No I don’t know

18 Hepatitis C Yes No I don’t know

19 Digestive disorders Yes No I don’t know

20 Colitis, irritable bowel syndrome (IBS) or Crohn’s disease Yes No I don’t know

21 Kidney stones or kidney diseases Yes No I don’t know

22 Dermatological problems Yes No I don’t know

23 Shingles Yes No I don’t know

1
Please, remember, that non-vaccinated students bear full liability in case of being infected with the disease.
 Have you undergone surgical operation (if yes, do you have
24 metallic implants? Write in details in section “Notes” Yes No I don’t know

(please include operation name, date))

25 Menstrual irregularities (for girls!) Yes No I don’t know

Other diseases (Write in details in section “Notes” (disease

26 Yes No I don’t know
name, date))

c. Notes (if space is not enough, use separate paper)

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
________________________________________________
d. Please, enumerate medication you take on regular basis (write dosage, times per day)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
________________________

I, __________________________________________________________, confirm that aforementioned

information submitted by myself is correct, and I assume full responsibility for false medical data.

Signature: ______________________________

Date: __________________________________
 List of medical documents
Medical documents meeting following requirements are to be submitted in Kyrgyz, Russian or
English languages. If document is written in another language, a translation of the document must be
attached and notarized in accordance with the legislation of KR. Original copies of the reports must be
attested with a seal of the medical institution, a seal and a signature by the doctor.
Medical documents must be submitted to the AUCA Medical Office.
Health certificates:
1) Vaccination information (similar to the #063-form in Kyrgyz Republic) – original +
photocopy.

2) Tuberculosis
The examination must include: a fluorography, OR X-ray radiograph, OR computed X-ray
tomography (CT scan) for chest organs, made not later than 6 months prior to the submission of
the documents to AUCA. Imaging, its description, and medical report (originals) must be
submitted.
If Medical Office will have any questions about medical description or translation, it can request a
retest.
3) HIV/AIDS
Medical report (original of the test result) on the basis of blood analysis, made not later than 1 month
prior to submission of documents to AUCA.
4) Syphilis
Medical report (original of the test result) on the basis of blood analysis for micro-precipitation test,
Wasserman test or Polymerase chain reaction (PCR), made not later than 1 month prior to submission of
documents to AUCA.
5) Malaria
Medical report (original of the test result) on the basis of blood analysis for malaria (a thick
blood smear method), made not later than 1 month prior to submission of documents to AUCA.

6) Viral hepatitis B
In case of absence of vaccination information (similar to the #063-form in Kyrgyz Republic), please
submit medical report (original of the test result) on the basis of blood analysis for marker of viral hepatitis
B – HbsAg, made not later than 1 month prior to submission of documents to AUCA.

7) Measles and Rubella

In case of an absence of information about a vaccination, (similar to the #063-form in Kyrgyz Republic)
(see Information about student’s health status), please submit a medical report on the basis of blood
analysis for markers IgG and IgM for Measles and Rubella.
ATTENTION: if you submit information about vaccination against measles, rubella, and viral hepatitis
B (similar to the #063-form in Kyrgyz Republic), you are EXEMPTED from undergoing blood tests for
diseases aforementioned on the Paragraphs 6 and 7!