MKU/ADR/F007

STUDENT ENTRANCE MEDICAL EXAMINATION FORM

IMPORTANT: Students should bring this form duly signed during registration.

PART: (A) TO BE FILLED BY APPLICANT

(a) SURNAME___________________ OTHER NAMES _____________________

PHONE NUMBER_________________ EMAIL ___________________________

DATE OF BIRTH _____________________ GENDER ________________________

SINGLE/MARRIED ______________________RELIGION ____________________

NATIONALITY _____________________

SCHOOL ______________________________________________________________

(B) Name Address and Telephone Numbers of Parent/Guardian:

Name of the Parent/Guardian__________________________
Address ______________________________________________________________
Have you ever been admitted into a hospital? ___________________________________
If so, state reason for admission and date_______________________________________
_____________________________

(C) Have You Ever Had Any of the Following Illness?

Tuberculosis or other chest infection Yes/No__________________________________
Fits, Nervous disease or fainting attacks Yes/No ________________________________
Heart disease or rheumatic fever Yes/No ______________________________________
Any disease of genital – urinary system Yes/No _________________________________
Allergies to food or drug Yes/No ___________________________________________
Malaria Yes/No __________________________________________________________
Sexually transmitted disease Yes/No _________________________________________
Any disease of the digestive system Yes/No ___________________________________
If the answer to any of the above is yes, please give details with date ________________

(d) If there are any other relevant details of your medical history not covered by above, please give
particulars _____________________________________________________

(E) Does Any Member of Your Family Suffer From

(i) Insanity or mental illness? Yes/No

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 (ii) Tuberculosis Yes/No
(iii) Diabetes Mellitus Yes/No
(f) Have you been immunized against any of the following diseases:
Small Pox Yes/No _________________________ Date ________________________
Tetanus Yes/No _________________________ Date _________________________
Poliomyelitus Yes/No _________________________ Date ___________________
Student’s signature _________________________ Date _________________________

PART II TO BE COMPLETED BY THE EXAMINING MEDICAL

OFFICER/DOCTOR/PHYSICIAN
Name of student _________________________ Date ___________________
Height _________________________________ Weight _________________

VISUAL ACUTY
Without glasses R.6/ L.6/
Without glasses R.6/ L.6/
Hearing Right Ear Left Ear
Condition of teeth _________________________
Nose _________________________
Throat ________________________

Lymphatic Glands __________________________________________________

Circulatory system __________________________________________________
Blood Pressure ________________________________ Pulse ________________
Systolic ______________________________________ Diastolic ____________
Respiratory system __________________________________________________

X-RAY Chest if necessary ____________________________________________

THE STUDENT TO BE GIVEN THE CHEST X-RAY FILM TO BRING TO THE

UNIVERSITY’S MEDICAL OFFICER DURING REGISTRATION
Abdomen _________________________________________________________
Spleen ____________________________________________________________
Any Evidence of Hernia ______________________________________________
Urine _________________ Alburmin _______________ Sugar ______________
Any observation defects in addition to general record of observation __________
__________________________________________________________________

Blood Khan’s Test __________________________________________________

PART III PARENT/GUARDIAN

(a) Which hospital do you prefer for referral (admission) purposes in need be?
(If yes, which one)
Private ___________________________________________________________

Public ____________________________________________________________

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 Name of Doctor/Physician ____________________________________________

Signature _________________________ Official _______________________

PART IV (TO BE COMPLETED BY THE UNIVERSITY MEDICAL OFFICER)

Special remarks/comment____________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Does the student require any special medical needs?

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

DATE: _______________ UNIVERSITY MEDICAL OFFICER ____________

UNIVERSITY HEALTH SERVICES ____________