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    Medical History and Report 1

    Uploaded by

    Saharudin Bioscience
    This medical report provides information on a nominee's physical examination. It includes measurements of height, weight, blood pressure and pulse. It also notes vision, any current medications, pregnancy status and allergies. Laboratory tests are listed including blood group, hemoglobin levels, urinalysis and stool examination. The nominee's general physical exam and individual body systems are checked as normal or abnormal with additional comments. The examining physician provides opinions on the nominee's ability to study away from home physically and mentally as well as their risk of infectious disease or other conditions during the fellowship period. Any conditions requiring treatment are also noted.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Medical History and Report 1

    Uploaded by

    Saharudin Bioscience
    64 views3 pages
    This medical report provides information on a nominee's physical examination. It includes measurements of height, weight, blood pressure and pulse. It also notes vision, any current medications, pregnancy status and allergies. Laboratory tests are listed including blood group, hemoglobin levels, urinalysis and stool examination. The nominee's general physical exam and individual body systems are checked as normal or abnormal with additional comments. The examining physician provides opinions on the nominee's ability to study away from home physically and mentally as well as their risk of infectious disease or other conditions during the fellowship period. Any conditions requiring treatment are also noted.

    Original Description:

    Medical History Report for Scholarship in Thailand 2018

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    This medical report provides information on a nominee's physical examination. It includes measurements of height, weight, blood pressure and pulse. It also notes vision, any current medications, pregnancy status and allergies. Laboratory tests are listed including blood group, hemoglobin levels, urinalysis and stool examination. The nominee's general physical exam and individual body systems are checked as normal or abnormal with additional comments. The examining physician provides opinions on the nominee's ability to study away from home physically and mentally as well as their risk of infectious disease or other conditions during the fellowship period. Any conditions requiring treatment are also noted.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    64 views3 pages

    Medical History and Report 1

    Uploaded by

    Saharudin Bioscience
    This medical report provides information on a nominee's physical examination. It includes measurements of height, weight, blood pressure and pulse. It also notes vision, any current medications, pregnancy status and allergies. Laboratory tests are listed including blood group, hemoglobin levels, urinalysis and stool examination. The nominee's general physical exam and individual body systems are checked as normal or abnormal with additional comments. The examining physician provides opinions on the nominee's ability to study away from home physically and mentally as well as their risk of infectious disease or other conditions during the fellowship period. Any conditions requiring treatment are also noted.

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    © All Rights Reserved
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    Medical History and Report

    Name of Nominee ............................Age ..............................


    Country.

    *Physical Examination (To be filled in by physician)

    Present Status
    Height ... Cms. Weight .......kgs. Blood Pressure ... mm.Hg. Pulse .../min.
    Vision Right .....Left ...... Eyes .... With glasses / Without glasses
    a) Do you currently use any drugs for the treatment of a medical condition? (give name and dosage)
    ( ) No
    ( ) Yes : name of medication ( ), Quantity ( )
    b) Are you pregnant?
    ( ) No
    ( ) Yes : ( months)
    c) Are you allergic to any medication or food?
    ( ) No
    ( ) Yes : ( ) Medication : ( ) Food : ( ) Other:_________________________

    Laboratory Examinations

    Blood group .Blood film for malaria ...Hb .. gm%

    WBC .. Cells/cu.mm.

    Differential PMN . % Lymp .. % Mono .. % Eos .... %

    Baso .. % Band % Blast . %

    Urinalysis : Colour .. Sp. Gr pH . Sugar .

    Alb .. Blood .Ketones .. Blie

    Micro : WBC./HPF.,RBC ./HPF.,Epethelial. /HPF.

    Casts../ HPD., Others .

    Stool examination for parasite & Ova

    Chest X Ray report ..

    Urine pregnancy test ..


    Check each item in appropriate column

    Item Normal Abnormal Additional comment

    General ...

    Skin, Scalp ...

    Lymph nodes ...

    Eyes ...

    Ears ...

    Otoscopic Exam

    Nose ...

    Pharynx & tonsils ...

    Teeth ...

    Thyroid gland ...

    Lungs ...

    Heart ...

    Abdomen ...

    Liver ...

    Spleen ...

    Hernia ...

    External genitalia ...

    Rectal exam. ...

    Vertebrae ...

    Locomotor ...

    Reflexes ...

    Mental health status ...

    Is the nominee able physically and mentally to carry on intensive study away from home?

    Is the nominee free from infectious diseases (such as tuberculosis, leprosy, syphillis and
    filariasis) and other conditions (such as psychosis and drug addiction) which could present
    risks for anyone during the fellowship period?

    Does the nominee have any condition or defect which might require treatment during the
    fellowship period?

    Full name and address of


    Examining physician (printed)

    Physician signature .M.D.


    (.)
    Date .

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