How to Complete the Health Questionnaire Form in Namibia

As part of the application process for certain official purposes in Namibia, all applicants are required to complete a Health Questionnaire form. This form collects information about the applicant’s health history and any existing or past medical conditions. Follow the steps below to complete the form accurately:

Page 1 of the Health Questionnaire Form in Namibia

Official Use

• This section is for official use only and should be left blank.

Section A: Personal Information

• Fill in your surname (last name) in block letters in the designated space.
• Provide your first names in the designated space.
• Enter your age in years in the designated space.
• Provide your height in centimeters (cm) in the designated space.
• Enter your body mass in kilograms (kg) in the designated space.
• Fill in your identity number in the designated space.

Section B: Health History

• Read through each question in section B of the form.
• For each question, mark with an “X” in the appropriate column to indicate whether you have ever suffered from the condition or not (Yes/No).
• If you answer “Yes” to any of the questions, provide details of the nature, severity, date, and duration of the illness in the space provided. Be sure to provide accurate and complete information.

Page 2 of the Health Questionnaire Form in Namibia

Section B – Health History (continues)

Questions about Medical History

Bullet Points:

• Questions 6 to 9 are related to your medical history.
• For each question, mark with an “X” in the appropriate column if you have ever suffered from the condition mentioned.
• If your answer is “Yes”, provide details of the nature, severity, date, and duration of the illness in the space provided.
• Avoid using overly technical terms or jargon, and provide clear and concise information.

7. Any condition affecting the digestive system? Yes/No
   If your answer is “Yes”, provide details of the nature, severity, date, and duration of the illness in the space provided
8. Any condition affecting the urinary system and/or genital or reproductive organs? Yes/No
   If your answer is “Yes”, provide details of the nature, severity, date, and duration of the illness in the space provided
9. Any condition affecting the nervous system or mental illness? Yes/No
   If your answer is “Yes”, provide details of the nature, severity, date, and duration of the illness in the space provided
10. Any other illness? Yes/No
    If your answer is “Yes”, provide details of the nature, severity, date, and duration of the illness in the space provided

Section C – Sensory Impairment and Disability

Questions about Sensory Impairment and Disability

Bullet Points:

• Questions 1 and 2 are related to sensory impairment and disability.
• If your answer is “Yes”, provide details of the nature and severity of the disability in the space provided.
• Use plain language and avoid technical terms or jargon.

1. Do you have any sensory impairment e.g. hearing, speech, or sight? Yes/No
   If your answer is “Yes”, provide details of the nature, severity, date, and duration of the illness in the space provided
2. Do you have any disability? (physical, mental, or any other impairment that substantially restricts you in one or other way of an individual’s major life activities) Yes/No
   If your answer is “Yes”, provide details of the nature, severity, date, and duration of the illness in the space provided

Section D – Surgery/Operation History

Questions about Surgery/Operation History

Bullet Points:

• Question is related to surgery/operation history.
• If your answer is “Yes”, provide details of the nature and date of the surgery/operation in the space provided.
• Use simple language and avoid technical terms or jargon.

Have you undergone any surgery/operation(s)? Yes/No
If your answer is “Yes”, provide details of the nature, severity, date, and duration of the illness in the space provided

Section E – Declaration

Declaration

Bullet Points:

• This section is for declaring that the above information is true and correct, and that you have not withheld any information regarding your health.
• Provide your signature and date in the space provided.

Example: I do hereby declare that the above information is true and correct and that I have not withheld any information regarding my health. Signature: (Provide your signature) Date: (Provide the date)

Completing the Health Questionnaire Form in Namibia accurately and with authority is crucial to ensure that the authorities have the necessary information to assess your health condition. By following the guidelines provided and answering the questions truthfully and to the best of your knowledge, you are helping the authorities assess your health condition effectively.

Remember to provide relevant details about the nature, severity, date, and duration of any illnesses or surgeries, using plain language and avoiding technical terms or jargon. Additionally, ensure to sign and date the declaration section to confirm the accuracy of the information provided. By completing the form with authority and providing insightful information, you are contributing to a comprehensive assessment of your health and assisting the authorities in making informed decisions.

You can download the Health Questionnaire Form here.

Frequently Asked Questions

We will provide you with detailed answers to commonly asked questions about the health questionnaire form in Namibia. So, let’s dive in and get your FAQs written in no time!

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