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AA F003 Medical Form

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79 views2 pages

AA F003 Medical Form

Uploaded by

cliveino31
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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AA/F003

KARATINA UNIVERSITY
OFFICE OF THE REGISTRAR
(ACADEMIC, RESEARCH & STUDENT AFFAIRS)
P.O. Box 1957 - 10101 KARATINA TEL: +254 (0)716 135 171/(0)723 683 150
[email protected]/[email protected] www.karu.ac.ke

STUDENT’S MEDICAL FORM


IMPORTANT:
Students are requested to dully complete Part I of this Form. Part II should be completed by the
Medical Officer examining the student. To be completed in CAPITAL letters.
PART I
a) Student’s Name:
…………………………………………………………………………………………………………
(Surname, Middle name, Last name)
Registration Number: ………………………………………………………………………………
School: ………………………………………………………………………………………………..
National ID/ Birth Certificate Number: ………………………………………………………..…
NIIMS Huduma Number: ………………………………………………………………………….
National Hospital Insurance Fund (NHIF) Card No: …………………………………………...
Date of Birth (DD/MM/YY): ………………………………………………………………………
Gender: Male Female
Nationality: ………………………………………………………………………………………….
Marital Status: Single: Married: Divorced: Widowed:
Name and contacts of Parent/Guardian/Next of Kin.
i. Name: …………………………………….. Relationship: …………………………………
P.O. Box: ……………… Code: …………………. Town: …………..…………………….
Mobile Phone No: …………………………… Email: …………………………………….
b) Have you ever been admitted into a hospital? Yes No
If so, state reason for admission and date: ……………………………………………………….
…………………………………………………………………………………………………………
c) Have you ever had any of the following illnesses (tick appropriately);
i. Tuberculosis or other chest infections? Yes No
ii. Fits, Nervous disease or fainting attacks Yes No
iii. Heart Disease or Rheumatic Fever. Yes No
iv. Any disease of the Digestive System. Yes No
v. Allergies to food or drugs. Yes No
vi. Sexually Transmitted diseases. Yes No
vii. Poliomyelitis. Yes No
If the answer to any of the above is Yes, please give details with dates: ……………………...
…………………………………………………………………………………………………………
If there are any other - relevant details of your medical history not covered by the above
questions, please give particulars. ………………………………………………………………...
…………………………………………………………………………………………………………
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d) Has any members of your family suffered from:
i. Tuberculosis. Yes No
ii. Insanity or mental illness. Yes No
iii. Diabetes Mellitus. Yes No
iv. Heart Disease. Yes No

e) Have you been immunized against any of the following diseases?


i. Small pox. Yes No Date immunized:………………………
ii. Tetanus. Yes No Date immunized:………………………
iii. Poliomyelitis. Yes No Date immunized:………………………
I certify that the information I have provided is correct.

……………………………………. ………………………………………..
Signature of Student Date

PART II – (To be completed by the Examining Medical Officer)


a) Height. ………………………………. Weight. ………………………………………
b) Visual Acuity:
Without glasses.………………………………….
With glasses R.6 …………………………………… L.6. ………………..………………………...
c) Hearing: Right Ear………………………………… Left Ear………………………………………
d) Condition of: Teeth:…………………….. Throat:………………………………………………
Ears:…………………………………… Lymphatic glands:…………………………………
Nose:…………………………………..
e) Circulatory System: Pulse: ……………………….. Heart………………………………..
Blood Pressure……………… Systolic …………………………Diastolic………………………..
f) Respiratory System………………………………………………………………………………….
Chest X-Ray (Optional depending on Clinical findings)……………………………………………
g) Abdomen: Any Palpable Masses-Physiological or Pathological?…………………………….
…………………………………………………………………………………………………………
Liver………………………………………………………………………………………………….
Spleen…………………………………………………………………………………………………
Uterus……………………………………… L.M.P…………………………………………
h) Urine Albumin…………………………….. Sugar………………………………………….
i. Is the student on any treatment?…………………………………………………………..
ii. Any other observation of importance?………………………………………………….

…………………………………………… ………………………. ………………………


Name of Examining Medical Officer Signature Date & Stamp

PART III – (To completed by Karatina University Medical Doctor, after the student has
registered with the University)
Special Remarks:……………………………………………………………………………………………..
…………………………………………………………………………………………………………………
Is the student fit for University Education? Yes No

………………………………………….. ………………………. ………………………


Name of University Medical Officer Signature Date & Stamp
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