The Hebrew University of Jerusalem The Robert H. Smith Faculty of Agriculture, Food & Environment International School of Agricultural Sciences Personal Medical Statement 2016 First and middle name (as it appears on your Chinese passport): Family name (as it appears on your Chinese passport): Instructions: Please complete the application, print out and send by mail with the other documents in the application process. Do not leave any blank spaces. Incomplete applications will not be considered. The Hebrew University reserves the right to require the applicant to undergo a further medical examination before or during the period of studies. If you answer "yes" to any question, please include dates in the field on the right and explain on a separate page. 1. Have you had in the past or do you now have problems related to: Date Heart (cardiovascular), lung and/or respiratory system (Tuberculosis, asthma, tumor, etc.) Yes No Stomach, intestines, liver, kidney (nephritis, stones, etc.) Yes No Nervous system (convulsions, stroke, mental illness, stress-related disorders, etc.) Yes No Glandular system (such as goiter, diabetes, anemia) Yes No Skin, muscles, bones, joints Yes No Sensory organs (eyes, ears, etc.) Yes No STD (sexually transmitted diseases), including HIV Yes No 2. Has any member of your family had: Date Tuberculosis Yes No Mental illness Yes No Asthma Yes No Epilepsy Yes No Malaria Yes No STD (sexually transmitted diseases), including HIV Yes No DECLARATION I, the undersigned, understand and agree that the University reserves the right to take any necessary measures in connection with candidates who submit partial, incorrect and/or false information, and certify that all information given here is full and correct. I waive my right to privacy regarding all medical information and documentation relevant to processing my application to the study program. Date (dd/mm/yy): Applicant's Signature: Noa Schwarzwald, Head of International Programs International School for Agricultural, Robert H. Smith Faculty of Agriculture, Food & Environment, Herzl Street, POB 12, Rehovot, Israel 7610001 Email: [email protected] Tel: 972-8-9489996 Fax: 972-8-9470171 The Hebrew University of Jerusalem The Robert H. Smith Faculty of Agriculture, Food & Environment International School of Agricultural Sciences Noa Schwarzwald, Head of International Programs International School for Agricultural, Robert H. Smith Faculty of Agriculture, Food & Environment, Herzl Street, POB 12, Rehovot, Israel 7610001 Email: [email protected] Tel: 972-8-9489996 Fax: 972-8-9470171