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    FORM MksU4-STUDENTS ENTRANCE MEDICAL EXAMINATION

    Uploaded by

    Richard Osumo
    This document is a student entrance medical examination form for Machakos University. It collects medical history information from the student in Part 1, including any hospitalizations, illnesses, immunizations, and family medical history. Part 2 is completed by the examining medical officer, who evaluates the student's physical exam, including vision, hearing, dental/throat exams, vital signs, and any notes. Chest x-rays may be required. Part 3 is completed at the University and indicates if the student is fit for education and whether any ongoing treatment is required.

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

    FORM MksU4-STUDENTS ENTRANCE MEDICAL EXAMINATION

    Uploaded by

    Richard Osumo
    118 views4 pages
    This document is a student entrance medical examination form for Machakos University. It collects medical history information from the student in Part 1, including any hospitalizations, illnesses, immunizations, and family medical history. Part 2 is completed by the examining medical officer, who evaluates the student's physical exam, including vision, hearing, dental/throat exams, vital signs, and any notes. Chest x-rays may be required. Part 3 is completed at the University and indicates if the student is fit for education and whether any ongoing treatment is required.

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    Medical form

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    This document is a student entrance medical examination form for Machakos University. It collects medical history information from the student in Part 1, including any hospitalizations, illnesses, immunizations, and family medical history. Part 2 is completed by the examining medical officer, who evaluates the student's physical exam, including vision, hearing, dental/throat exams, vital signs, and any notes. Chest x-rays may be required. Part 3 is completed at the University and indicates if the student is fit for education and whether any ongoing treatment is required.

    Copyright:

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

    FORM MksU4-STUDENTS ENTRANCE MEDICAL EXAMINATION

    Uploaded by

    Richard Osumo
    This document is a student entrance medical examination form for Machakos University. It collects medical history information from the student in Part 1, including any hospitalizations, illnesses, immunizations, and family medical history. Part 2 is completed by the examining medical officer, who evaluates the student's physical exam, including vision, hearing, dental/throat exams, vital signs, and any notes. Chest x-rays may be required. Part 3 is completed at the University and indicates if the student is fit for education and whether any ongoing treatment is required.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    FORM MksU/4

    MACHAKOS UNIVERSITY
    OFFICE OF THE REGISTRAR (ACADEMIC & STUDENT AFFAIRS

    University Admission No._______________

    STUDENT ENTRANCE MEDICAL EXAMINATION

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

    NOTE: A chest X-ray may be required if the doctor examining a student, feels that it is necessary. The
    film should be given to the student to bring to the University Medical Officer during the registration
    period.

    PART 1: (a) SURNAME__________________ OTHER NAMES________________________

    DATE OF BIRTH_____________ GENDER______________________________

    NATIONALITY______________ SINGLE/MARRIED_____________________

    RELIGION__________________

    SCHOOL____________________________________________________________

    NAME, ADDRESS AND TELEPHOINE NUMBER OF PARENT/GUARDIAN:

    __________________________________________________________________________________

    ______________________________________________________________________________

    NEXT OF KIN__________________________________________________________________

    (b) Have you ever been admitted to hospital?________________________________________

    If so, state reason for admission and date:_________________________________________

    __________________________________________________________________________

    1
    FORM Mksu/4

    (c) Have you had any of the following illnesses?

    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 genitor-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 dates.

    ______________________________________________________________________________

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

    ______________________________________________________________________________

    ______________________________________________________________________________

    (e) Has any member of your family suffered from

    (i) Tuberculosis Yes/No

    (ii) Insanity or mental illness Yes/No

    (iii) Diabetes Mellitus Yes/No

    (f) Have you been immunized against any of the following diseases:-

    (i) Small pox Yes/No_________________ Date:_______________

    (ii) Tetanus Yes/No_________________ Date:_______________

    (iii) Polymyelistis Yes/No_________________ Date:_______________

    Student’s Signature_____________________________________________________________________

    PART II (To be completed by the examining Medical Officer)

    (a) Height________________________________________ Weight___________________


    2
    FORM Mksu/4

    (b) VISUALACUTITY

    Without Glasses R.6/ L.6/


    Without Glasses R.6 L.6/

    (c) Hearing Right Ear Left Ear

    (d) Condition of: Teeth_______________________________________________


    Nose_______________________________________________
    Throat______________________________________________

    (e) Lymphatic Glands________________________________________________________


    Circulatory System_______________________________________________________
    Blood Pressure___________________________________________________________
    Systolic_________________________________________________________________
    (f) Respiratory System_______________________________________________________
    _______________________________________________________________________
    X-Ray (Chest of necessary)_________________________________________________
    _______________________________________________________________________

    NB: THE STUDENT SHOULD BE GIVEN THE CHEST – RAY FILM TO BRING TO THE
    UNIVERSITY OFFICE OF THE DEAN OF STUDENTS DURING REGISTRATION

    (g) Abdomen________________________________________________________________

    Spleen__________________________________________________________________

    Any Evidence of Hernia____________________________________________________

    Any evidence of Hermorrhoids______________________________________________

    (h) Urine_____________________ Albumin__________________ Sugar_______________

    3
    FORM Mksu/4

    (i) Any observation defects in addition to general record of observation.


    ______________________________________________________________________________
    ______________________________________________________________________________
    (j) Blook Khan Test________________________________________________________________
    (k) Any other observation of importance________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________

    Name:__________________________________________ Signature________________________
    Date:__________________________________________ Address:_________________________
    ________________________________
    ________________________________

    Rubber Stamp_____________________

    PART III
    (To be completed at the University)

    SPECIAL REMARKS

    Fit/Unfit for University Education


    Is/is not on treatment at present

    DATE:______________________ SIGNATURE:_______________________________________
    OFFICE OF THE DEAN OF STUDENTS

    Machakos University

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