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MEForm

Uploaded by

liberalstudies
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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MEDICAL EXAMINATION FORM

PART 1: BACK GROUND

SURNAME: ………………………OTHER NAME………………………………………. GENDER…….…

DATE OF BIRTH: ……………………………PLACE OF BIRTH ………………………..

NATIONALITY: …………………MARITAL STATUS………………………………………………….

TELEPHONE NO. (SELF)………………………

NEXT OF KIN: …………………..…………………………..

POSTAL ADDRESS: ……………………………………….……………………………..

TELEPHONE NO.: ……………………………………………………………..

PART II:
Have you ever been admitted into hospital? ………………………………………………………..
If so, when and for what illness? ……………………………………………………………………
Have you ever suffered from any of the following? …………………………………………………………………...
Allergy Yes/No Infectious Mononucleosis Yes/No
Anaemia Yes/No Jaundice/Hepatitis Yes/No
Asthma Yes/No Peptic Ulcer Yes/No
Back problem Yes/No Mental illness Yes/No
Bilharzia Yes/No Poliomyelitis Yes/No
Bladder problem Yes/No Severe headaches Yes/No
Chest infections Yes/No Surgery Yes/No
Diabetes mellitus Yes/No Thyroid disease Yes/No
Epilepsy Yes/No Tuberculosis Yes/No
Eye problem Yes/No Speech problem Yes/No
Heart disease Yes/No Hearing problem Yes/No
High blood pressure Yes/No Sexually transmitted disease Yes/No
Blood transfusion Yes/No Irregular menstrual periods Yes/No
Are you on any treatment now? Yes/No
If the answer to any of the above is YES, please give details (can use separate sheet)
.........................................................................................................................................................................................
.........................................................................................................................................................................................

Who’s your doctor? ........................................................................................................................................................

Any other medical cover, including SHA? ……………………….. ....................................................


FAMILY MEDICAL HISTORY:
Has any member of your family suffered from any of the following?
Diabetes mellitus Yes/No Heart disease Yes/No
High blood pressure Yes/No
Mental illness Yes/No Sickle cell disease Yes/No
Tuberculosis Yes/No

SIGNATURE……………………….. DATE …………………………………………..

PART III: (To be completed by the Examining Doctor) ……………………………………………..


Immunization Record
B.C.G(yes/no), P o l i o m y e l i t i s (yes/no) DPT (yes/no) Hepatitis(yes/no)

Height ……… Weight ………………………. Any deformity ………………………………

Visual Acuity ………….. LE 6 ……………………… RE 6 …………………………………….


With glasses………………………………………………………………..
Without glasses…………………………………………………………….
E.N.T
Hearing ………………………….. Nose ……………………………………..
Throat ………………………
LYMPHATIC SYSTEM………………….………………………………………………………….
CARDIOVASCULAR SYSTEM:
Pulse ………………….… /minute Regular/irregular …….……………………………….
Heart sounds...………………………………… Blood pressure ………………………………
RESPIRATORY SYSTEM:
Clinical findings ……………………………………Respiratory rate ……………….
Percussion……………………………………… Auscultation………………………
CXR, X-Ray and report should be submitted together with the form. (IF NECESSARY)
ALIMENTARY SYSTEM:
Teeth……………………..Tongue…………………………Abdomen …………………………
GENITO-URINARY SYSTEM:
Urethral discharge………..…………….L.M.P.……………………………...Uterus ………………
LABORATORY TEST
Urine:-S.G.…………..Albumin……………………….Sugar……………Deposit………….
Blood:-Khan Test…………………………..
COMMENTS BY THE EXAMINING DOCTOR:
………………………………………………………………………………………………………
……………………………………………………………………………………………………
DOCTOR’S NAME…………… …………………………. SIGNATURE
……………………. STAMP………………

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