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BVMD Health Form for Medical Students

This health form from the Bundesvertretung der Medizinstudierenden in Deutschland e.V. must be completed by a physician to confirm a student's immunization status and physical health. Only test results from within the past three months will be accepted. The form requires documentation of vaccinations or immunity for COVID-19, hepatitis A and B, measles/mumps/rubella, varicella, pertussis, tetanus, diphtheria, poliomyelitis, tuberculosis, and influenza. The physician must sign, date and stamp the completed form.

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MAHAK JUNEJA KUMAR RANI
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156 views3 pages

BVMD Health Form for Medical Students

This health form from the Bundesvertretung der Medizinstudierenden in Deutschland e.V. must be completed by a physician to confirm a student's immunization status and physical health. Only test results from within the past three months will be accepted. The form requires documentation of vaccinations or immunity for COVID-19, hepatitis A and B, measles/mumps/rubella, varicella, pertussis, tetanus, diphtheria, poliomyelitis, tuberculosis, and influenza. The physician must sign, date and stamp the completed form.

Uploaded by

MAHAK JUNEJA KUMAR RANI
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Bundesvertretung der Medizinstudierenden in Deutschland e.V.

Health Form

Health Form

Please have this form completed by your Physician/General Practitioner or University


Medical Centre.
ONLY results from tests taken three months prior to submission of the application form will
be accepted.
ALL sections of the form must be completed in full. Incomplete documentation will not be
accepted.

Hereby I certify that I examined [name] , born [birth date] ,


and found that she/he is in good physical and mental health and protected against the infectious diseases
listed below by means of vaccination or proof of sufficient antibody count.
Tick if applicable. Please make sure to attach laboratory results.

COVID vaccination Date vaccine (e.g. Pfizer)


 1st Dose _______________ __________________
 2nd Dose _______________ __________________
 3rd Dose _______________ __________________
 optional: Booster shot: _______________ __________________
if only 2 shots were received:
 prior infection proven with PCR
Please attach a laboratory proof.

Hepatitis A Date:
 1st Dose
 2nd Dose
OR
 serological proof of immunity

Place, date Signature Stamp (name, address)

Version Okt 2022

[Link] 1/3 buero@[Link]


Bundesvertretung der Medizinstudierenden in Deutschland e.V.
Health Form

Hepatitis B Date:
 1st Dose
 2nd Dose
 3rd Dose
AND to prove immunity
 Anti-HBs Result: _________ (m)IU/(m)L
Note: it should be > 100 mIU/ml =100 IU/L and is not the same as HbS-Ag!

Hepatits C Date:
 Anti-HCV-antibodies

HIV Date:
 Anti-HIV-antibodies

Measles/Mumps/Rubrella (MMR) – Vaccination Date:


 1st Dose
 2nd Dose

Varicella Date:
 1st Dose
 2nd Dose
 OR Past infection
 OR Vaccination titer/serology

Pertussis Vaccination Date:


 last vaccination was within the last 10 years

Tetanus Vaccination Date:


 Full immunization

Place, date Signature Stamp (name, address)

Version Okt 2022

[Link] 2/3 buero@[Link]


Bundesvertretung der Medizinstudierenden in Deutschland e.V.
Health Form

Diphteria Vaccination Date:


 Full immunization

Poliomyelitis Date:
 Full immunization

Pulmonary Tuberculosis [one is sufficient] Date:


 BCG Scar [yes/no]
 Mantoux tuberculin skin test [positive/negative]
 Chest X-Ray

Influenza vaccination [optional!] Date:


 Vaccinated

Place, date Signature Stamp (name, address)

Version Okt 2022

[Link] 3/3 buero@[Link]

Common questions

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The form allows for different ways to demonstrate immunity, such as vaccine doses, past infection evidence, or serological proof. This flexibility accommodates individual variations in immunity acquisition, recognizing that immunity can be attained through multiple pathways .

The form provides three options for proving immunity against pulmonary tuberculosis: presence of a BCG scar, results of a Mantoux tuberculin skin test, or a chest X-Ray, with any one of these sufficing as evidence .

Immunity against Varicella can be verified through documentation of either the first and second doses of the vaccination, evidence of a past infection, or by using a vaccination titer/serology test .

Completing all sections of the health form is crucial as incomplete documentation will not be accepted, potentially delaying or invalidating the application process. Full completion ensures all necessary health and vaccination information is provided .

Tests submitted with the health form must have been conducted within three months prior to the submission of the application form .

Strict adherence to the health form's vaccination requirements helps prevent the spread of infectious diseases within medical environments, where students are at higher risk of exposure. Ensuring immunity among medical students limits potential outbreaks and protects vulnerable populations they interact with, demonstrating a proactive approach to public health management .

The health form lists the Influenza vaccination as optional. Although not mandatory, it is suggested to help protect individuals from seasonal flu outbreaks, which is particularly important in settings where infectious diseases spread rapidly .

The form requires the dates and brands of each COVID-19 vaccination dose to be listed. If only two doses have been administered, proof of a prior COVID-19 infection via PCR test must be attached .

The form includes a wide range of required vaccinations and tests, such as for COVID-19, Hepatitis A and B, measles, mumps, rubella, varicella, pertussis, tetanus, diphtheria, poliomyelitis, and tuberculosis. Each vaccine requirement is paired with either vaccination dates or proof of immunity through serology, ensuring thorough protection against potential outbreaks .

For Hepatitis B, the form requires an Anti-HBs result to be provided. The value must be greater than 100 mIU/ml to confirm immunity. This value signifies adequate antibody protection, which is distinct from the presence of HbS-Ag .

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