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Medical Examination Form

This student entrance medical examination form collects medical information from the applicant and examining doctor. It requests information about the applicant's personal details, medical history, family medical history, immunization history, and physical examination results. The examining doctor provides information on the physical exam, including vital signs, and tests like urine analysis and blood Khan's test. The form is to be signed by the applicant and their parent/guardian and completed during student registration, with follow up by the university medical officer if needed.

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chumbefred
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8K views3 pages

Medical Examination Form

This student entrance medical examination form collects medical information from the applicant and examining doctor. It requests information about the applicant's personal details, medical history, family medical history, immunization history, and physical examination results. The examining doctor provides information on the physical exam, including vital signs, and tests like urine analysis and blood Khan's test. The form is to be signed by the applicant and their parent/guardian and completed during student registration, with follow up by the university medical officer if needed.

Uploaded by

chumbefred
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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MKU/ADR/F007

STUDENT ENTRANCE MEDICAL EXAMINATION FORM


IMPORTANT: Students should bring this form duly signed during registration.

PART: (A) TO BE FILLED BY APPLICANT

(a) SURNAME___________________ OTHER NAMES _____________________

PHONE NUMBER_________________ EMAIL ___________________________

DATE OF BIRTH _____________________ GENDER ________________________

SINGLE/MARRIED ______________________RELIGION ____________________

NATIONALITY _____________________

SCHOOL ______________________________________________________________

(B) Name Address and Telephone Numbers of Parent/Guardian:


Name of the Parent/Guardian__________________________
Address ______________________________________________________________
Have you ever been admitted into a hospital? ___________________________________
If so, state reason for admission and date_______________________________________
_____________________________

(C) Have You Ever Had Any of the Following Illness?


Tuberculosis or other chest infection Yes/No__________________________________
Fits, Nervous disease or fainting attacks Yes/No ________________________________
Heart disease or rheumatic fever Yes/No ______________________________________
Any disease of genital – urinary system Yes/No _________________________________
Allergies to food or drug Yes/No ___________________________________________
Malaria Yes/No __________________________________________________________
Sexually transmitted disease Yes/No _________________________________________
Any disease of the digestive system Yes/No ___________________________________
If the answer to any of the above is yes, please give details with date ________________

(d) If there are any other relevant details of your medical history not covered by above, please give
particulars _____________________________________________________

(E) Does Any Member of Your Family Suffer From


(i) Insanity or mental illness? Yes/No

1
(ii) Tuberculosis Yes/No
(iii) Diabetes Mellitus Yes/No
(f) Have you been immunized against any of the following diseases:
Small Pox Yes/No _________________________ Date ________________________
Tetanus Yes/No _________________________ Date _________________________
Poliomyelitus Yes/No _________________________ Date ___________________
Student’s signature _________________________ Date _________________________

PART II TO BE COMPLETED BY THE EXAMINING MEDICAL


OFFICER/DOCTOR/PHYSICIAN
Name of student _________________________ Date ___________________
Height _________________________________ Weight _________________

VISUAL ACUTY
Without glasses R.6/ L.6/
Without glasses R.6/ L.6/
Hearing Right Ear Left Ear
Condition of teeth _________________________
Nose _________________________
Throat ________________________

Lymphatic Glands __________________________________________________


Circulatory system __________________________________________________
Blood Pressure ________________________________ Pulse ________________
Systolic ______________________________________ Diastolic ____________
Respiratory system __________________________________________________

X-RAY Chest if necessary ____________________________________________

THE STUDENT TO BE GIVEN THE CHEST X-RAY FILM TO BRING TO THE


UNIVERSITY’S MEDICAL OFFICER DURING REGISTRATION
Abdomen _________________________________________________________
Spleen ____________________________________________________________
Any Evidence of Hernia ______________________________________________
Urine _________________ Alburmin _______________ Sugar ______________
Any observation defects in addition to general record of observation __________
__________________________________________________________________

Blood Khan’s Test __________________________________________________

PART III PARENT/GUARDIAN


(a) Which hospital do you prefer for referral (admission) purposes in need be?
(If yes, which one)
Private ___________________________________________________________

Public ____________________________________________________________

2
Name of Doctor/Physician ____________________________________________

Signature _________________________ Official _______________________

PART IV (TO BE COMPLETED BY THE UNIVERSITY MEDICAL OFFICER)


Special remarks/comment____________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Does the student require any special medical needs?


__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

DATE: _______________ UNIVERSITY MEDICAL OFFICER ____________


UNIVERSITY HEALTH SERVICES ____________

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