FP 100 – Health certificate
HA
Name:_________________________________________Date of birth/CPR-No.:___________________________
Occupation:_________________________________________________________________________________
Address:_________________________________Postal code:______City/town:___________________________
To the applicant:
 You must contact your doctor (GP) to have this certificate filled in. Please be sure to inform the doctor, that
your appointment is concerning the filling in of a Health Certificate FP100.
 You must read the answers and sign the cerficate to confirm that all health issues are included. It is your
responsibility that the certificate is answered correctly.
 According to the Danish Insurance Contract Act, the insurance may be cancelled or coverage reduced if the
information is incomplete, incorrect or information has been withheld.
To the doctor:
 The certificate is a general health certificate and alle questions must therefore be answered. In this case please
supply additional information concerning: ____________________________________________________
PART I: DOCTOR’S INFORMATION
1
a Are you the doctor normally used by
the applicant?
b Do you know the applicant?
No Yes
 
If YES, since when?_________(month/year)
 
If NO, how did you determine the identity of the
applicant?____________________________________
PART II: DOCTOR’S QUESTIONS TO THE APPLICANT WITH NOTES ON THE PATIENT.
1 Please question the patient about previous and current illnesses, examinations, treatments, use of drugs/medicine, alcohol,
tobacco and stimulants. Please enclose relevant patient notes, for example doctor’s notes or certificates, discharge letters and
laboratory results.
2 Do not inform about the results of genetic testing with regard to the patient’s risk of certain future diseases (predictive
genetic testing).
3 Please be aware of the consequence for the patient, if incomplete information is supplied, cf. the Danish Insurance Contract
Act (see above).
1
Please state: Diagnosis, time of debut of symptoms, time of
diagnose, progress and present symptoms.
Does the applicant suffer from or has
the applicant previously suffered
from:
a Infectious diseases (except ordinary
colds), for example cerebrospinal
meningitis, rheumatic fever, tropical
diseases, malaria, HIV/AIDS?
No
Yes


No
Yes


No
Yes
Please enclose supplementary patient notes
including the results of paraclinical tests.
b Tumours (benign and malignant
tumours), for example cancer, including
early stage cancer, blood and lymphatic
cancer, polyps, cysts and other benign
tumours?
Please state: Diagnosis, time of debut of symptoms, time of
diagnose, progress and present symptoms.
Please enclose supplementary patient notes
including the results of paraclinical tests.
c Diseases of the blood, for example
Please state: Diagnosis, time of debut of symptoms, time of
diagnose, progress and present symptoms.


No
Yes


e Mental conditions, for example
depression, nervousness, anxiety, stress,
mental reaction etc.?
No
Yes


Has the patient had suicidal tendencies
or been subject to cases of poisoning?


No
Yes


No
Yes


anaemia, bone marrow diseases ,
coagulation and immunological diseases
and diseases of the spleen?
Please enclose supplementary patient notes
including the results of paraclinical tests.
d Metabolic disorders, for example
diabetes (including glucosuria and
gestational diabetes), struma or
metabolic disturbances and elevated
blood cholesterol?
Please state: Diagnosis, time of debut of symptoms, time of
diagnose, progress and present symptoms.
NB: For endocrine disorders (including
dyslipidemia) please state laboratory
measurements and treatment.
Please enclose supplementary patient notes
including the results of paraclinical tests.
Please state: Diagnosis, time of debut of symptoms, time of
diagnose, progress and present symptoms.
Please enclose supplementary patient notes
including the results of paraclinical tests.
f Diseases of the nervous system
(including eye or ear diseases), for
example headache or migraine,
vertigo/dizziness, epilepsy, fainting or
cramps, paralyses or mobility
disturbances, cerebral haemorrhage,
blood clot in the brain, sensation
disturbances including multiple sclerosis
(MS)?
Please state: Diagnosis, time of debut of symptoms, time of
diagnose, progress and present symptoms.
Please enclose supplementary patient notes
including the results of paraclinical tests.
g Cardiac, circulatory or vascular
disorders, for example hypertension,
chest pain (angina pectoris), palpitation
or irregular heart rhythm, blood clot,
heart or heart valve disease, varicose
veins or phlebitis, blood clot in legs,
intermittent claudication (claudicatio
intermittens)?
Please state: Diagnosis, time of debut of symptoms, time of
diagnose, progress and present symptoms.
Side 2
NB: In case of hypertension please state initial
bloodpressure, present treatment and for how
long treatment has taken place.
Please enclose supplementary patient notes
including the results of paraclinical tests.
h Pulmonary or respiratory diseases, for
example asthma, hay fever or allergy,
bronchitis, COPD/COLD, tuberculosis,
blood clot in a lung, lung infections,
silicosis, emphysema and sarcoidosis?
No
Yes


No
Yes


No
Yes


No
Yes


No
Yes


Please state: Diagnosis, time of debut of symptoms, time of
diagnose, progress and present symptoms.
Please enclose supplementary patient notes
including the results of paraclinical tests.
i Diseases of the digestive system
(stomach, intestinal, liver, gall bladder
and pancreas), for example ulceration
(ulcus) or bleedings, oesophagus
discomforts or reflux, indigestion
(irritable bowel syndrome, celiac disease
or allergy), colitis, ileus, polyps, jaundice
or hepatitis, gallstones, fatty liver
(steatosis), abnormal liver count
(demonstrated through blood tests),
pancreatitis?
Please state: Diagnosis, time of debut of symptoms, time of
diagnose, progress and present symptoms.
Please enclose supplementary patient notes
including the results of paraclinical tests.
j Skin diseases, for example eczema
(including allergy), skin cancer, psoriasis,
infections (including abscesses), blisters
and venereal diseases?
Please state: Diagnosis, time of debut of symptoms, time of
diagnose, progress and present symptoms.
Please enclose supplementary patient notes
including the results of paraclinical tests
(including histology results).
k Diseases in or discomfort from the
neck, back or loin, for example muscle
tensions, ischias, discusprolaps, low back
pain, whiplash, diseases of the spine,
scoliosis?
Please state: Diagnosis, time of debut of symptoms, time of
diagnose, progress and present symptoms.
Please enclose supplementary patient notes
including the results of paraclinical tests.
l Diseases of the joints, tendons, bones
or connective tissue, for example injuries
to tendons or joints, osteoarthritis,
arthritis/rheumatism, fibromyalgia,
osteroporosis, hypermobility or pelvic
girdle pain?
Please state: Diagnosis, time of debut of symptoms, time of
diagnose, progress and present symptoms.
Side 3
Please enclose supplementary patient notes
including the results of paraclinical tests.
m Kidney or urinary diseases and
diseases relating to male or female
genitals (including complications during
pregnancy), for example nephritis,
cystitis, kidney or bladder stone, blood,
protein or bacteria in the urine, removal
of kidney, malformations or cysts, female
gynecological problems or male urinary
problems (including prostatic
enlargement?
No
Yes


No
Yes


No
Yes


Please state: Diagnosis, time of debut of symptoms, time of
diagnose, progress and present symptoms.
Please enclose supplementary patient notes
including the results of paraclinical tests.
n Other diseases than the above
mentions, apart from non-complicated
childhood diseases, ordinary shortterm
and non-recurring infectious diseases and
complications due to cosmetic
treatments?
Please state: Diagnosis, time of debut of symptoms, time of
diagnose, progress and present symptoms.
Please enclose supplementary patient notes
including the results of paraclinical tests.
2
a Has the applicant ever been injured?
If YES, when?_________________________
Month/Year
What was the nature of the injury?_______________
___________________________________________
If YES, are there any complications?
 
___________________________________________
Please enclose supplementary patient notes
including the results of paraclinical tests.
Questions 2. b, c and d about illness in the
family is answered on the basis of information
from the applicant himself only.
b Has one of the applicant’s close
relatives (parents, siblings, children)
been diagnosed with cancer before the
age of 55?
If YES, which symptoms as well as percentage of
permanent injury (if any)? ________________________
No
Yes


If YES:
Which relative?______________________________
kinship
Which disease?______________________________
__________________________________________
At what age was the disease diagnosed?
Side 4 __________
c Are there or have there been hereditary
diseases among the applicant’s close
relatives (parents, siblings, children)?
No
Yes


If YES:
Which relative?______________________________
kinship
Which disease?______________________________
NB: Do not inform about the results of genetic
testing with regard to the patient’s risk of
certain future diseases (predictive genetic
testing.
__________________________________________
At what age was the disease diagnosed? __________
d Has one of the applicant’s close
relatives (parents, siblings, children)
been diagnosed with an arteriosclerotic
disease before the age of 60?
No
Yes


If YES:
Which relative?______________________________
kinship
Which disease?______________________________
__________________________________________
At what age was the disease diagnosed? __________
3
Has the applicant been ill or unable to
work for a longer period of time (more
than one month?
No
Yes


If YES:
During which periods?_________________________
Month/year
For which reason?__________________________
4
Has the applicant (apart from the above
mentioned) received medical treatment
for more than one month or received
recurring medical treatment, including
tranquilizers or painkillers?
No
Yes
If YES:


For which reason?__________________________
During which periods?_________________________
At present? No
 Yes 
Month/year
5
Does the applicant use or has he used
euphoriants (for example heroin, speed,
cocaine, ecstasy, LSD), cannabis, organic
solvents, anabolic drugs, or other
stimulating or tranquilizing substances?
No
Yes


If YES:
During which periods?_________________________
At present? No
 Yes 
Month/year
Which substances?____________________________
Any complications? No  Yes  Which?___________
____________________________________________
6
a Does the applicant drink beer, wine,
dessert/fortified wine or liquor?
No
Yes


If YES:
Number ____ of drinks per week (on average)
b Has the applicant previously had a
larger consumption of beer, wine,
dessert/fortified wine or liquor?
No
Yes


If YES:
Number ____ of drinks per week (on average)
During which periods?_________________________
Month/year
Side 5
c Has the applicant ever received
treatment or counselling for an excessive
consumption of beer, wine,
dessert/fortified wine or liquor?
No
Yes


If YES:
During which periods?_________________________
At present? No
 Yes 
Month/year
Which treatment/counselling?____________________
What was the effect of the treatment/counselling? ___
___________________________________________
7
a Does the applicant smoke?
No
Yes
If YES:


Daily consumption:_________________________
(number of cigarettes, cigars, pipes)
b Has the applicant smoked previously?
No
Yes
If YES:


During which periods?_________________________
Month/year
Daily consumption:_________________________
(number of cigarettes, cigars, pipes)
I have reviewed the answers and hereby declare the above information to be true and accurate and that nothing
has been withheld. I am aware that the insurance may be cancelled or coverage reduced if the information is
incomplete, wrong or if information has been withheld.
_________
Date
________________________________________
Applicant’s signature
___________________
CPR-No.
Side 6
PART III: DOCTOR’S EXAMINATION
1
Applicant’s height and weight.
Height (without shoes):________cm.
Weight (in indoor clothes):_________kg.
2
Is there any abnormality of:
No
Yes


b Eyes, including faculty of vision with
best correction?


Faculty (with correction) Right:____ Left:_____
c Ears, including sense of hearing with
best correction?


Sense of hearing (with correction):___________
d Chest, including deformities and
mobility?


e Lungs, including stethoscopy?


a Head, oral cavity, pharynx, throat?
If YES, please describe.
Sense of hearing can be measured by
whispering and speaking at a distance of 4
m.
Peakflow measurements by lung disease:
Measurement 1:
Measurement 2:
Measurement 3:
For lung disease including asthma and
bronchitis
symtoms,
peakflow
measurements
please
include
3
(possibly
a
spirometri).
f
Heart
and
vessels
including
stethoscopy,
pulse
and
blood
pressure?


3 different recordings are required at an
Pulse
Blood pressure
Rythm:
______
Systolic
Frequency:
Diastolic
Measurem
Measurem
Measurem
ent 1:
ent 2:
ent 3:
interval of at least 1 minute after the
applicant has rested for at least 5 minutes.
______
In case of newly discovered hypertension:


Has further assessment or treatment
been initated?
Which?_______________________________________


including


i Arms, legs and joints, for example
varicose veins, oedemas, peripheral


g Abdomen, i.e. palpable masses,
organ tumours, soreness, scars?
A gynaecological or rectal examination is
not required.
h
Vertebral
column,
abnormal curving?
Side 7
pulses, signs of existing or
phlebitis, muscular dystrophy?
3
past
j The skin and lymph nodes (neck,
armpit, groin)?


k Outer sexual organs,
plapation of breasts?
including


l Examination of the nervous system,
for
example
tremors,
reflexes,
abnormality of tactile sensations?


Urine examination by stix.
Albumin
Sugar
Blood
If positive reaction, please state below the result of any
immediately following check-up examination.
Follow-up date:_____________________________
Result:
Albumin
No
Yes


In case of newly discovered reactions:
Does anything in the applicant’s
appearance or behaviour indicate any
kind of weakness or sickliness
including any mental disorder?
Do you consider the applicant:
Blood
If YES:
Which?______________________________________
Has further assessment or treatment
been initated?
4
Sugar
No
Yes


If YES:
How?_______________________________________
____________________________________________
Yes
No
If NO:
5
Well (without any signs of illnesses)?
Fully capable of work?
 
Why not?___________________________________
 
Why not?___________________________________
This health certificate has been completed by me
in accordance with my notes on and knowledge of
the applicant plus my questioning and examination
which took place:
Please forward the certificate in a closed envelope
marked HEALTH CERTIFICATE to:
_______________________________________
Date
Doctor’s signature
Full address (stamp):
Side 8
Payment may take place to the NemKonto
regisstered for the CPR-/CVR-/SE-number stated
below.
CPR-/CVR-/SE-number:_____________________
Giro/Bank:
Registrationnumber and accountnumber:
________________________________________
The certificate has been approved by the certificate committee of the Danish Medical Association and will at once be paid by the
insurance company after submission of an invoice for the price agreed with the Danish Medical Association.
04.01.01.02.
Side 9