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    Confidential: Medical History and Personal Particulars of Students Joining at IIT Madras

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    Neha
    This document contains a medical examination report for students joining IIT Madras. It collects personal information and medical history, including any past treatments, illnesses, allergies, or family history of medical conditions. It also documents the results of a physical examination and various medical tests by specialists in general medicine, ophthalmology, and ENT. The concluding certification states whether the candidate is deemed fit to pursue higher education based on the examination results.

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    Confidential: Medical History and Personal Particulars of Students Joining at IIT Madras

    Uploaded by

    Neha
    134 views4 pages
    This document contains a medical examination report for students joining IIT Madras. It collects personal information and medical history, including any past treatments, illnesses, allergies, or family history of medical conditions. It also documents the results of a physical examination and various medical tests by specialists in general medicine, ophthalmology, and ENT. The concluding certification states whether the candidate is deemed fit to pursue higher education based on the examination results.

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    This document contains a medical examination report for students joining IIT Madras. It collects personal information and medical history, including any past treatments, illnesses, allergies, or family history of medical conditions. It also documents the results of a physical examination and various medical tests by specialists in general medicine, ophthalmology, and ENT. The concluding certification states whether the candidate is deemed fit to pursue higher education based on the examination results.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    134 views4 pages

    Confidential: Medical History and Personal Particulars of Students Joining at IIT Madras

    Uploaded by

    Neha
    This document contains a medical examination report for students joining IIT Madras. It collects personal information and medical history, including any past treatments, illnesses, allergies, or family history of medical conditions. It also documents the results of a physical examination and various medical tests by specialists in general medicine, ophthalmology, and ENT. The concluding certification states whether the candidate is deemed fit to pursue higher education based on the examination results.

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    CONFIDENTIAL Annexure V

    Medical Examination Report


    Medical History and personal particulars of Students joining at IIT Madras
    1. Full Name (in capitals) …………………………………………………..………………………
    2. JEE (Adv) 2019 Roll No. …………………………… IIT M Roll No.……..…………………
    3. Name of Parent/Guardian ………………………………………………………………………..
    4. Personal : Veg. / Non-Veg.
    Abuse of substances (if any) : Smoking / Alcohol / Drugs / Any other
    5. Past Medical/Surgical Treatment : No Yes

    5.1 Allergies/Bronchial Asthma/Tuberculosis


    5.2 Abdomen including Urinary Tract
    5.3 Locomotor system (Spinal/Vertebral column/Joints)
    5.4 Cardiovascular system
    5.5 Neurological disorders/Psychological disorders
    5.6 Sexually-transmitted/Venereal Diseases/Skin
    5.7 Hepatitis
    5.8 Diabetes
    5.9 Rheumatism
    5.10 Thyroid disease

    6. Family history of any major illness : No Yes


    6.1 Tuberculosis
    6.2 Leprosy
    6.3 Diabetes
    6.4 Hypertension
    6.5 Ischemic heart diseases
    6.6 Psychiatric illness
    6.7 Cancer
    7. Identification marks : 1)

    2)

    8. Blood Group :

    I declare that all the statements above are true and correct to the best of my knowledge. I fully
    understand that I am responsible for the accuracy of all statements given.

    Candidate’s Signature : ………………………………………………………………………….

    Counter signed by Parent/Guardian………………………………………………………………….

    Date :

    Place : P.T.O. (2)

    26
    :2:

    HEALTH CERTFICATE

    1. Examination by a General Physician (M.D. in General Medicine)

    I, Dr. ……………………………………………………………………………………………………
    after examining (with necessary investigations) Mr./Ms. ……………………………………………
    Son / Daughter of Mr./Ms. ……………………………………………………………………………….
    born on …………………………

    CERTIFY:

    Weight ………. Kg. Height ………. cm. Blood Pressure ………….. / ................. mm Hg.

    Girth of Chest : (a) At rest ……………………. : (b) After deep inspiration ………………………..

    Cardiovascular System : Heart ………………… Heart Sounds ……………

    Respiratory System :

    Neurological System :

    Psychological disturbance : Yes / No If yes, specify


    ………………………………….

    Past Medical or Surgical Record :

    Identified allergies :

    Current treatments :

    Current vaccination Status (All candidates who do not have adequate active/passive immunity against
    diseases mentioned below should take these injections/adult booster dose as recommended, just before
    joining the Institute and the date to be mentioned below):

    VACCINATION AGAINST 1st Injection Last Booster


    DISEASES Date Yes / No Date Yes / No
    BCG
    Diphtheria – Tetanus - Poliomyelitis
    Measles, Mumps, Rubella
    Hepatitis B
    Hepatitis A
    Meningitis
    Typhoid
    Chicken Pox
    Influenza Vaccine (H1N1)

    Candidate’s Signature : …………………………………………………………….

    P.T.O. (3)
    27
    :3:
    INVESTIGATIONS

    1. *Electrocardiogram Date ……………………….. Result ………………………

    2. *Chest X-ray Date ……………………….. Result ………………………

    3. *Sonography (whole abdomen) Date ……………………….. Result ………………………

    4. *Urine Date ………………………. Result ………………………

    5. *Blood Tests Date ……………………….. Result ………………………

    a) Blood Sugar (F/PP) Date ……………………….. Result ………………………

    b) Urea/Creatinine Date ……………………….. Result ………………………

    c) Peripheral Smear Study/HB% Date ……………………….. Result ………………………

    d) Lipid Profile Date ……………………….. Result ………………………

    e) Blood Group/typing (if not known) Date ……………………….. Result ………………………

    f) HBS Ag Date ……………………….. Result ………………………

    g) HIV – I & II Date …………………….. Result ………………………

    *All original investigation reports (only) to be attached.

    Remarks / Special Recommendation, if any:

    Conclusion : 1. Fit / Unfit to pursue higher education with a very tight academic schedule.
    2. Does not suffer from any seizure disorder and he/she is fit for swimming

    Reason :

    Date :

    Place : Signature & Seal

    Candidate’s Signature : …………………………………………………………………………….

    P.T.O. (4)

    28
    :4:
    2. Examination by Ophthalmologist*

    Acuity of Far Vision Near Vision Colour Vision


    Vision Naked Eye With Glasses Naked Eye With Glasses
    R.E.

    L.E.

    *Latest Optometrist’s Recommendations, if any to be attached in original.

    Remarks / Special Recommendation, if any :

    I, Dr. …….……………………………………………………………………………………………..
    have examined (with necessary investigations) Mr./Ms. ……………………………………………
    Son / Daughter of Mr./Ms. ……..……………………………………………………….………….
    born on ................................................ and the above information given to the best of my knowledge
    are correct and true.

    Date :

    Place : Signature & Seal

    3. Examination by ENT Specialist*

    Inspection / hearing *Audiometry


    Right Ear
    Left Ear

    *Latest Audiometry report to be attached in original.

    Remarks / Special Recommendations, if any.

    I, Dr. ................................................................................................................................................. have


    examined (with necessary investigations) Mr./Ms. ………………...…………………………………
    Son / Daughter of Mr./Ms. ……..…………………………………………………..…….…………….
    born on ................................................ and the above information given to the best of my knowledge
    are correct and true.

    Date :

    Place : Signature & Seal

    Candidate’s Signature : ………………………………………………………………………

    29

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