Medical assessment questionnaire for residence in Spain

Complete this 4-part form to apply for your Spanish Medical Certificate of Good Health. You will be required to pay for the service at the end of this form.

Personal details

Your General Practitioner (GP)

Please provide contact details of your General Practitioner (GP). It may be necessary for us to contact these individuals on
your behalf.

Other Doctors / Medical Professionals  

(Optional)

Please provide the details of any other significant doctors/medical professionals that it may be important to include.

Employment information

Are you currently working?

Tick one box only

For unemployed, please select ‘Yes’ and write Unemployed in the details box

Lifestyle habits

Do you smoke?

Tick one box only

Do you drink alcohol?

Tick one box only

Functional Difficulties

Please provide information regarding your physical abilities and constraints.

Do you have any trouble with the following tasks? (Select yes or no) *
Yes
No

Driving a vehicle over rough roads, or for long periods of time

Tick one box only

Climbing ladders

Tick one box only

Walking for more than 1 hour, or on rough ground

Tick one box only

Going up or down stairs

Tick one box only

Lifting 15kg or heavy luggage

Tick one box only

Using hand tools, carrying tool bags, or elevating your hands above your head

Tick one box only

Walking, moving, completing basic daily activities (requiring support)

Tick one box only

COVID Vaccination History

Are you vaccinated against COVID-19? *

Tick one box only

If not, do you have a date for your vaccine appointment? *

Tick one box only

Are you double-vaccinated against COVID-19? *

Tick one box only

Medical History

Please answer the following questions regarding your medical history *
Yes
No

Have you had a heart attack or chest pain in the past 5 years?

Tick one box only

Have you had a stroke in the last 5 years?

Tick one box only

Are you taking anticoagulant medications?

Tick one box only

Do you have mobility limitations? Do you need a cane, crutches or wheelchair?

Tick one box only

Do you need help with basic activities of daily living (eating, grooming, dressing, etc.)?

Tick one box only

Do you have problems with anxiety, insomnia or depression?

Tick one box only

Have you seen a psychiatrist, or had a psychology consultation in the last 5 years?

Tick one box only

Do you suffer from Diabetes and/or High Blood Pressure and/or increased lipids (Cholesterol, Triglycerides) in your blood?

Tick one box only

Do you have any endocrinological or metabolic problems?

Tick one box only

Do you have, or have you had any serious infectious diseases in the past 5 years?

Tick one box only

Are you under medical treatment for a chronic disease?

Tick one box only

Do you have, or have you had cancer in the last 5 years?

Tick one box only

Surgery History

Have you had any surgeries in the last 10 years?

Tick one box only

 List the most relevant surgeries you have had in the last 10 years:

1
2
3
4
5

Medication

 List the medications you are currently taking on a regular basis and what they are for:

1
2
3
4
5
6
7
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9

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Terms and conditions

Payment

Price: £195.00

The service will not commence until payment has been made in full.