Medical Report Form

THE CATHOLIC UNIVERSITY OF EASTERN AFRICA
MEDICAL REPORT

Part I : To be completed by applicant in the presence of Medical examiner.

Name in full

Sex     Date of Birth

Address     Contact

Part II: DECLARATION (Applicant)

I, the above mentioned, do hereby certify that I have carefully considered my answers to the questions below and that, to the best of my knowledge and belief, the information given is complete and correct.

1. Have you suffered from any of the following? (give dates for each ‘Yes’ answer)

(a) Fits or convulsions or sudden loss of consciousness Yes No Date

- Head injury or ‘Concussion’ Yes No Date

- Nervous breakdown Yes No Date

- Any other Nervous trouble Yes No Date

(b) - Tuberculosis of the lungs Yes No Date

- Asthma or ‘Hey fever’ Yes No Date

(c) - Fainting attacks or Giddiness Yes No Date

- Heart diseases, ‘Weak heart’ or strained heart Yes No Date

- Pain in the heart, throat or arm while undertaking physical effort Yes No Date

(d) - Kidney or bladder trouble Yes No Date

- Difficulty or pain in passing urine Yes No Date

- Syphilis or Gonorrhoea Yes No Date

(e) - Any eye or ear complaints Yes No Date

(f) - Injury or disease of bones or joints Yes No Date

(g) - Skin diseases Yes No Date

(h) - Vericose veins Yes No Date

(i) - Chronic conditions; Diabetes, Arthritis, HIV, Hypertension. Yes No Date

2. Have you ever suffered from any illness or injury not mentioned above Yes No Date

3. Are you on current medication for any condition? Yes No Date

4. What operations have you had?

5. Family History

Is there any family member known to have; Diabetes, Hypertension, Epilepsy, Heart disease, Strokes, Sudden death, Cancer Yes No Date

Part III: To be completed by Medical examiner

GENERAL EXAMINATION

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

RESPIRATORY SYSTEM

CENTRAL NERVOUS SYSTEM

GASTRO- INTESTINAL SYSTEM

GENITO – URINARY SYSTEM

MUSCULO – SKELETOL SYSTEM

FEMALES:

Menstrual History

Investigations required:

Part IV : CERTIFICATE

This is to certify that I have examined and find him/ her:-

(1.) In good health and fit for further education

(2.) Free / not free from any mental or physical defect to be aggravated or to endanger the life, health or safety of himself/ herself or others in the course of his/ her education.

Part V: For official use ONLY.

FIT / UNFIT FOR STUDIES AT THE CATHOLIC UNIVERSITY OF EASTERN AFRICA.