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CPCE Medical Form

The document is a medical form for teacher-trainees at the Cyril Potter College of Education, requiring personal information and a health questionnaire to be completed by both the trainee and a medical examiner. It includes sections on personal history, medical history, and a detailed examination of various body systems. The medical examiner must conclude on the candidate's suitability for the teacher training program based on the provided information and examination results.

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2 views5 pages

CPCE Medical Form

The document is a medical form for teacher-trainees at the Cyril Potter College of Education, requiring personal information and a health questionnaire to be completed by both the trainee and a medical examiner. It includes sections on personal history, medical history, and a detailed examination of various body systems. The medical examiner must conclude on the candidate's suitability for the teacher training program based on the provided information and examination results.

Uploaded by

liasonjohnny07
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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CYRIL POTTER COLLEGE OF EDUCATION

MEDICAL FORM
Medical Report on the Health of the Teacher -Trainee for admission to the Cyril Potter College of Education

A. To be completed by the Teacher-Trainee.


1. ________________________ ___________________________________________________________
Surname Forename(s)
2. Sex: Male [ ] Female [ ]
3. Date of Birth: _________ _________ _______________
Year Month Day
4. Place of Birth:
___________________________________________________________________________
5. Address: _______________________________________________________________________________
6. Place of Employment: ____________________________________________________________________
7. Marital Status: Single [ ] Married [ ] Divorced [ ] Widowed [ ] Common Law [ ]
8. Number of Children: _______________________

QUESTIONNAIRE – Personal History


B. To be Completed by the Medical Examiner
Please answer YES or NO.
Have you ever had:
If yes, GIVE details of description, dates and duration,
etc.
a) An allergy – hay fever, Asthma?

b) Back injury, Arthritis, Osteomyelitis,


Rheumatic Fever, Disorder of Bones,
Joints or Spine?

c) Epilepsy- fits, convulsions


Nervous breakdown, Nervous or
Mental Trouble, Fainting Spells,
Dizziness, Insomnia?

d) (i) Wine, beer, spirit or any other form


of alcohol – State amount and
frequency.
(ii) Habit forming drugs? If so, to what
extent? And have you ever sought
advice or treatment for alcohol or drug
addiction?

e) Treatment for diabetes, high or low


pressure, disorders of the heart or
blood vessel? (Hemorrhoids and
Varicose Veins included)
f) Habitual cough, Pleurisy, Tuberculosis
or disorder of the Respiratory System?

g) Indigestion, Ulcer, disorder of the


Stomach, Intestine, Gallbladder or
Liver?

Please answer YES or NO.


Have you ever had:
If yes, GIVE details of description, dates and duration,
etc.
h) Kidney Stones or Colic, disorder of
the Genitor – Urinary System Male
(Female) organs?

i) Cancer, Tumor, Syphilis, disorder of


the Blood, Skin or Lymphatics

j) Treatment or observation in any


hospital or institution?

k) Any accident, injury or operation other


than those mentioned above?

Question (l) and (m) to be answered by females only.


l) A Miscarriage or Caesarean Section?

m) Any pregnancies? If so, how many


and what is the most recent?

These questions are answered truly to the best of my knowledge and belief, I understand
that any misrepresentation of facts in a reasonable basis for release.

_______________________________________ ________________________
Signature of Teacher-Trainee Date
C. To be Completed by the Medical Examiner

System Examined Details


1. General
a) General Appearance

b) Nose

c) Tonsils and Pharynx

d) Teeth

e) Neck

f) Lymph nodes

2. Respiratory
a) Is the chest well-formed and developed?

b) Is the expansion good and equal?

c) Do percussion and auscultation reveal any


evidence of disease?

d) X-ray if indicated

System Examined Details


3. Cardiovascular
a) Apex Hearth

b) Pulse rate:
● At rest
● Immediately after exercise
● Two minutes after exercise

c) Blood pressure (by auscultatory method)d


having been assured that the patient is under
no form of treatment which may influence
reading).

d) Did physical effort cause undue cardiac or


respiratory distress?

e) Is there any sign of Cardiac Failure?

4. Abdomen
a) If spleen, kidney or liver is enlarged, or mass
found, state extent.
b) Hernia, Piles, Hydrocele.

c) Extremities- deformities
Elephantiasis, Varicosities, Ulcers or Skin
disease.

d) Back

e) Skin, including marks of severe injury, scars


or operations and signs of disease.

5. Nervous
a) Eyes – External Appearance

b) Colour Vision

c) Pupils

d) i) Acuity with glasses


ii) Acuity without glasses

e) Eye Movements

f) Fundi

g) Ear
i) External Appearance
ii) Hearing

h) Power and Tone of Muscles

i) Romberg’s Sign

j) Plantar Reflex

k) Psychological assessment of patient during


history taking an examination.

6. Any other observations?


D. Conclusion

1. Taking all the evidence into consideration and reviewing carefully all the features of the case, do you
consider the candidate suitable for undertaking physical and mental demands of a teacher training
programme?

_________________________________________________________________________________
_________________________________________________________________________________

2. If found unfit for training, the case and its permanency or otherwise, should be clearly stated,
together with a recommendation as to whether the candidate should be re-examined at a stated
interval after treatment.

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

_______________________________________ ________________________
Signature of Medical Examiner Date

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