The Medical Self Declaration Form is a vital document used across various sectors in South Africa where disclosure of personal health information is necessary for medical, occupational, or administrative purposes. It is designed to capture comprehensive health information while complying with South African legislation, including the Protection of Personal Information Act (POPIA) and National Health Act. The form typically includes sections covering current health status, medical history, medications, allergies, and lifestyle factors. It serves multiple purposes, from pre-employment medical screening to health risk assessments for insurance or participation in activities. The document ensures that all relevant health information is properly disclosed, documented, and protected, while providing a basis for informed decision-making by healthcare providers, employers, or other authorized parties.
Your data doesn't train Genie's AI
You keep IP ownership of your information
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
OR
Let Genie AI's market-leading legal AI identify missing terms, unusual language, compliance issues and more - in just seconds.
Upload your Doc
1. Personal Information: Basic identification details including full name, ID number, date of birth, contact information, and emergency contact details
2. Declaration of Understanding: Statement confirming that the declarant understands the purpose of the form and implications of their declarations
3. Current Health Status: Declaration of present health conditions, symptoms, or concerns
4. Medical History: Details of past medical conditions, surgeries, hospitalizations, and chronic conditions
5. Family Medical History: Relevant hereditary conditions and significant family health issues
6. Current Medications: List of all current medications, including prescribed, over-the-counter, and supplements
7. Allergies and Reactions: Documentation of known allergies to medications, substances, or environmental factors
8. Lifestyle Factors: Information about smoking, alcohol consumption, exercise, and other relevant lifestyle factors
9. Certification and Signature: Declaration of truth and accuracy, with space for signature and date
1. COVID-19 Status and History: Section for COVID-19 vaccination status, previous infections, and current symptoms - optional based on current health regulations and requirements
2. Mental Health Declaration: Additional section for mental health status and history - included when required for specific medical or employment purposes
3. Pregnancy Status: For female patients of childbearing age when relevant to medical treatment or employment conditions
4. Occupational Health Information: Details of work-related health risks and exposures - included when form is used for employment purposes
5. Travel History: Recent travel information - included during epidemic/pandemic situations or for specific medical screening purposes
6. Disability Declaration: Additional section for declaring any disabilities - included when relevant for accommodation or support purposes
1. Schedule A: Detailed Medical Conditions List: Comprehensive checklist of common medical conditions for reference
2. Schedule B: Medication List Template: Structured template for listing current medications with dosages and frequencies
3. Schedule C: Privacy Notice: Detailed information about how the declared medical information will be used, stored, and protected
4. Appendix 1: Medical Terms Glossary: Definitions of medical terms used in the form for better understanding
5. Appendix 2: Emergency Contacts Form: Detailed emergency contact information and preferred healthcare providers
Relevant legal definitions
Declarant
Medical Condition
Chronic Condition
Pre-existing Condition
Healthcare Provider
Medical History
Personal Information
Sensitive Personal Information
Medical Professional
Emergency Contact
Prescribed Medication
Over-the-counter Medication
Allergic Reaction
Medical Treatment
Occupational Health Assessment
Informed Consent
Medical Confidentiality
Healthcare Facility
Medical Examination
Physical Impairment
Mental Health Condition
Hereditary Condition
Lifestyle Factor
Privacy Notice
Medical Records
Data Processing
Authorized Representative
Medical Emergency
Health Risk
Disclosure
Medical Condition
Chronic Condition
Pre-existing Condition
Healthcare Provider
Medical History
Personal Information
Sensitive Personal Information
Medical Professional
Emergency Contact
Prescribed Medication
Over-the-counter Medication
Allergic Reaction
Medical Treatment
Occupational Health Assessment
Informed Consent
Medical Confidentiality
Healthcare Facility
Medical Examination
Physical Impairment
Mental Health Condition
Hereditary Condition
Lifestyle Factor
Privacy Notice
Medical Records
Data Processing
Authorized Representative
Medical Emergency
Health Risk
Disclosure
Clauses
Personal Information
Medical History
Current Health Status
Privacy and Confidentiality
Consent
Information Processing
Declaration of Truth
Data Protection
Medical Records Access
Emergency Contacts
Disclosure Authorization
Information Updates
Rights and Obligations
Liability
Governing Law
Authentication
Information Storage
Third Party Disclosure
Medical Emergency Provisions
Amendments
Medical History
Current Health Status
Privacy and Confidentiality
Consent
Information Processing
Declaration of Truth
Data Protection
Medical Records Access
Emergency Contacts
Disclosure Authorization
Information Updates
Rights and Obligations
Liability
Governing Law
Authentication
Information Storage
Third Party Disclosure
Medical Emergency Provisions
Amendments
Relevant Industries
Healthcare
Insurance
Education
Sports and Recreation
Manufacturing
Mining
Construction
Transportation
Aviation
Maritime
Professional Services
Public Sector
Pharmaceuticals
Food and Beverage
Relevant Teams
Human Resources
Occupational Health and Safety
Risk Management
Compliance
Medical Services
Employee Relations
Recruitment
Operations
Legal
Administration
Relevant Roles
Human Resources Manager
Occupational Health Nurse
Health and Safety Officer
Medical Officer
Risk Manager
Compliance Officer
Employee Relations Manager
Insurance Underwriter
School Administrator
Sports Coordinator
Company Doctor
Recruitment Manager
Operations Manager
Workplace Health Coordinator
Industrial Hygienist
Find the exact document you need
Driving Licence Self Declaration Form
A South African regulatory document for self-declaring driving fitness and eligibility for obtaining or renewing a driving license under national traffic legislation.
find out more
Declaration Of Plagiarism
A South African legal document where authors declare their work is original and properly cited, in compliance with local copyright laws and academic integrity standards.
find out more
Declaration Of No Conflict Of Interest
A South African legal document where an individual formally declares the absence of any conflicts of interest that could impact their professional duties.
find out more
Declaration
A legally binding sworn statement certified by a Commissioner of Oaths under South African law, used to formally declare facts or intentions.
find out more
Legal Declaration
A formal sworn statement made under South African law, certified by a Commissioner of Oaths, serving as legal evidence of declared facts or intentions.
find out more
Declaration Of Interest
A South African legal document for declaring potential conflicts of interest and personal, professional, or financial interests as required by local corporate governance laws.
find out more
Form Of Declaration
A legally binding sworn statement certified by a Commissioner of Oaths under South African law, declaring specific facts or circumstances to be true.
find out more
Non Employment Self Declaration Form
A South African legal document declaring independent contractor status and distinguishing from employment relationships, compliant with local labor and tax laws.
find out more
Self Declaration Document
A legally binding sworn statement made under South African law, declared before a Commissioner of Oaths, used to formally verify facts or circumstances.
find out more
Nomination And Declaration Form
A South African legal document for nominating beneficiaries and declaring intentions regarding benefit distribution in financial and pension products.
find out more
Self Declaration Form For Job Application
A South African law-compliant self-declaration form for job applicants to declare personal information, employment history, and legal status for employment consideration.
find out more
Declaration Letter For Student
A legally binding document under South African law where students formally declare specific information or circumstances related to their academic status or personal situation.
find out more
Declaration Letter For Missing Documents
A formal sworn statement under South African law declaring the loss or absence of important documents, executed before a Commissioner of Oaths.
find out more
Declaration Letter For Employee
A formal employee declaration document under South African law used to record official statements or confirmations from employees regarding their circumstances, qualifications, or policy compliance.
find out more
Declaration Form For Scholarship
A South African legal document for scholarship applications and declarations, compliant with NSFAS and POPIA requirements, used for managing scholarship awards and recipient obligations.
find out more
Living Will Declaration Form
A South African legal document allowing individuals to specify advance healthcare directives and end-of-life treatment preferences.
find out more
Payment Declaration Letter
A formal South African document declaring payment details and confirming compliance with local financial regulations and requirements.
find out more
Self Declaration
A legally binding written statement under South African law where an individual formally declares certain facts or circumstances to be true, verified by a Commissioner of Oaths.
find out more
My Health Declaration
A South African law-compliant health declaration document for recording and declaring individual health status and medical history.
find out more
Health Declaration Form
A South African-compliant form for declaring personal health status and medical history, adhering to POPIA and National Health Act requirements.
find out more
Declaration Of Own Work
A South African legal document certifying the originality and authenticity of an individual's work, used in academic and professional settings.
find out more
Self Employment Declaration
A legal declaration document used in South Africa to formally establish and confirm an individual's status as self-employed or an independent contractor.
find out more
Thesis Declaration
A legally binding declaration document used in South African higher education institutions to confirm thesis originality and compliance with academic standards.
find out more
Signed Declaration Of Applicant And The Parent Legal Guardian
A South African legal document combining a minor's declaration with parental/guardian consent and authorization, authenticated by a Commissioner of Oaths.
find out more
Self Declaration Form For Scholarship
A legally binding declaration form used in South Africa for scholarship applications, containing personal, academic, and financial information declarations under oath.
find out more
Salary Declaration Letter
A formal South African employer-issued document confirming an employee's salary and compensation details for official purposes.
find out more
Parents Declaration Form For Scholarship
A South African legal document for parents to declare financial status and commit to scholarship terms for their child's education, compliant with local education and privacy laws.
find out more
Driving Licence Declaration Form
A South African legal document for declaring driving license status, qualifications, and related information under the National Road Traffic Act.
find out more
Declaration Of Undertaking
A formal legal document under South African law where a party makes binding commitments or promises to another party or authority.
find out more
Declaration In Lieu Of Affidavit
A formal South African legal document for declaring facts as true, signed before a Commissioner of Oaths, serving as an alternative to a sworn affidavit.
find out more
Custodian Of Records Affidavit
A sworn legal document under South African law certifying an individual's role as custodian of specific records and attesting to their authenticity and proper maintenance.
find out more
Age Declaration Form
A South African legal document for formal declaration of an individual's age, used for official age verification purposes.
find out more
Age Declaration Certificate
A legally binding document used in South Africa to formally declare an individual's age under oath, certified by a Commissioner of Oaths.
find out more
Declaration Of Domicile
A formal legal declaration under South African law establishing an individual's permanent residence and intention to remain in South Africa indefinitely.
find out more
Sworn Declaration
A South African legal document containing statements made under oath or affirmation, certified by a Commissioner of Oaths and used for official or evidentiary purposes.
find out more
Declaration Card
A mandatory customs and immigration declaration document required for all travelers entering South Africa, governed by South African customs and immigration laws.
find out more
Cargo Declaration
A mandatory customs document required under South African law that declares cargo details for imports, exports, or transit goods, governed by national customs legislation.
find out more
International Travel Declaration Form
A mandatory South African legal document for declaring personal, travel, health, and customs information for international travel.
find out more
Declaration Of Origin
A South African customs document certifying the country of origin of exported goods, complying with national customs regulations and international trade agreements.
find out more
Vat Declaration Form
A mandatory South African tax form for declaring VAT collections, payments, and calculations to SARS by registered VAT vendors.
find out more
Genie’s Security Promise
Genie is the safest place to draft. Here’s how we prioritise your privacy and security.
Your documents are private:
We do not train on your data; Genie’s AI improves independently
All data stored on Genie is private to your organisation
Your documents are protected:
Your documents are protected by ultra-secure 256-bit encryption
We are ISO27001 certified, so your data is secure
Organizational security:
You retain IP ownership of your documents and their information
You have full control over your data and who gets to see it
.png)
.png)