Medical and Psychological History Format for Asylum
This template or application letter can be used to document the medical and psychological history of a person seeking asylum. Properly recording any physical harm or psychological trauma can be crucial during the application process, especially if the applicant has previously received medical treatment. This format can be used and adapted by anyone, simply by replacing the relevant data.
Medical and Psychological History Format for Asylum
[Full Name of the Applicant]
[Date of Birth]
[Nationality]
[Identification or Passport Number]
Current Address: ___________________________
Phone Number: __________________________
Physical harms sustained:
________________________________________________________
________________________________________________________
Detailed description of the physical harm (including date and location):
________________________________________________________
________________________________________________________
________________________________________________________
Psychological traumas sustained:
________________________________________________________
________________________________________________________
Detailed description of psychological trauma (including date and location):
________________________________________________________
________________________________________________________
________________________________________________________
Medical treatment history (specify dates, locations, and treating physicians):
________________________________________________________
________________________________________________________
________________________________________________________
Current medications:
________________________________________________________
________________________________________________________
Additional observations:
________________________________________________________
________________________________________________________
________________________________________________________
[Name and signature of the applicant]
[Date]
