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Medical Examination Form-July-2024

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46 views1 page

Medical Examination Form-July-2024

Uploaded by

godrichgeorge2
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Tanzanian Training Centre for International Health, Ifakara

Medical Examination Form


This form consists of 5 parts. Part I is to be completed by the applicant and the rest to be completed by
a registered medical doctor.
I. Personal Information
Surname : …………………………………………. First name(s): …………………………………………..
Date of birth : …………………………………………. Sex: …………………………………………..
Marital status : Single/married/widowed Nationality: …………………………………………..

II. Past Medical History


Has the examined suffered from any of the following? If yes check (√) against the diagnosis. If
not, please write a cross (X) in the appropriate space
 Tuberculosis  Poliomyelitis or other neurological disorder:
 Epilepsy specify ………..………………………..
 Asthma/Chronic respiratory disorder  Psychiatric disorder: …………………………..
 Hypertension/or any other cardiac disease:  Skin disease/allergies: ........…………………
specify …………………………………….
 Gynecological disorder
 Renal disorder
 Peptic ulcer disease
 Major surgery: Specify ...……………………..
 Diabetes mellitus  Any deformity: specify …………………………
 Any liver disease: specify:…………………………..

III. Physical Examination


EYES : Rt VA ……………………………….. Systemic Examination
Rt VA …………………………....... Cardio-respiratory system: ………………………..
EARS : Rt hearing ………………………… Abdominal Examination : …………………………..
Rt hearing ………………………… Musculoskeletal system: ……………………………

IV. Imaging and Laboratory Investigations

Haematology: Haemoglobin: ……………………………………. Chest X-ray: …………………………………


Fasting blood sugar: …………………………..
White cell count: ………………………………..

V. Conclusion
I have examined Mr/Miss/Mrs ____________________________________ and consider that
he/she IS/IS NOT physically and mentally fit to be admitted for AMO/CO course studies.
………………………………………………………….……..……… …………………………… …………………………..
Name (and Qualification) Signature Date

Address: ……………………………………………………………………………………………………………………………………..

P.O. Box 39, Ifakara, Tanzania ▪ Phone: +255 23 293 1532 ▪ [email protected] |1

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