Medical Disclosure Statement

A medical disclosure statement refers to the type of statement which is issued by an individual or an entity disclosing his/ her or its medical condition to a third party. The issuer of the statement describes in the document their medical state, their well being, weather they have any diseases of allergies. An individual may issue such a statement to meet certain professional or personal legal requirements to qualify for a job, a program etc. Disclosure statements may also be issued for a variety of other reasons. Given below is a sample of a medical disclosure statement wherein an individual is describing her medical state to qualify for the job of a field researcher.

Sample Medical Disclosure Statement

Date: 15th June, 2012.

Name of the Individual: Ms. Melanie Carmichael

Age: 25 years

Correspondence Address: House No. 46, 34th and Mains, Wisteria Valley, California, USA.

Contact No.: 643-876-956

Purpose of issuing the statement: To certify the eligibility for the position of a field researcher.

Medical Disclosure Statement:

Blood Group: O negative

Weight: 60 kilograms

Height: 167 cms

I have no life threatening diseases to the date of issuing this disclosure statement. I am fit to stay and work in the field conditions and environments. I do have a minute case of low blood sugar and low blood pressure, but these conditions are treatable by medicines. I have consulted my medical examiner who confirms to my ability to work in the conditions and environment which I may come across as a field research officer.


I declare that the information I have given above are true and accept legal consequences if any of the given information are wrong. The information stated above can be cross checked from my medical examiner, details are given below.

Name of the Medical Examiner: Dr. Maria Barnes

Name of the Medical Institution: The City Hospital