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Medical Form - 2025

The document is a medical form for students at the University of Guyana Medical Centre, collecting personal information, medical history, and emergency contact details. It includes sections for childhood illnesses, vaccinations, past hospitalizations, allergies, medications, and dietary preferences. The form requires a signature from a parent or guardian to confirm the accuracy of the information provided.

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zeyalourindo017
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11 views

Medical Form - 2025

The document is a medical form for students at the University of Guyana Medical Centre, collecting personal information, medical history, and emergency contact details. It includes sections for childhood illnesses, vaccinations, past hospitalizations, allergies, medications, and dietary preferences. The form requires a signature from a parent or guardian to confirm the accuracy of the information provided.

Uploaded by

zeyalourindo017
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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UNIVERSITY OF GUYANA MEDICAL CENTRE, TURKEYEN CAMPUS TELE #: 592 – 620 – 0119

MEDICAL FORM

NAME of STUDENT:……………………………………………………………………………………………………………………………………

GENDER:  MALE  FEMALE AGE: ………………… DATE OF BIRTH:


……………………………………….

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

RELIGION: ………………………………………………………………… STUDENT TEL #:


…………………………………………………….

CONTACT INFORMATION IN CASES OF EMERGENCY:

NAME: ……………………………………………………………………. RELATIONSHIP:


……………………………………………...

TELEPHONE #: ………………………………………………………… EMAIL ADDRESS: ……………………………………………..

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

Do you give consent for a teacher or medical professional to administer care in an emergency?

Yes No

PERSONAL HISTORY:

CHILDHOOD ILLNESSES:  ANEMIA  ASTHMA  SEIZURES/EPILEPSY  DIABETES

 TUBERCULOSIS  MALARIA

 OTHERS: ……………………………………………………………………………………………………

VACCINATIONS: FULLY  PARTIALLY (PLEASE ATTACHED COPY OF UPDATED VACCINATION


RECORDS)

PAST HOSPITALIZATION HISTORY:


ACCIDENT OR INJURIES:  NO  YES: ………………………………………………………………………….
…………………..

PAST SURGICAL HISTORY: Have you ever had a surgery?  YES  NO

If Yes, please specify:


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

ALLERGIES:  NO  YES:

 FOOD: ………………………………………………………………………………………………………..
………………………………………….

 MEDICATION: ……………………………………………………………………….…………………………………………………….
………….

 OTHER:
…………………………………………………………………………………………………………………………………………………..

MEDICATIONS:

Are you on any medications presently:  NO  YES:

If YES …………………………………………………………….…………………………………………………………………………………………..

DIET:  Non-vegetarian  Vegetarian  Other:


…………………………………………………………………….

These questions are answered to the best of my knowledge and belief:

PARENT/ GUARDIAN NAME: ……………………………………………………………………………………………………………………..

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


………………………………………….

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