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    Medical

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    Medical

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    Medical

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    40 views2 pages

    Medical

    Uploaded by

    ols704652
    Medical

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    © All Rights Reserved
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    LADOKE AKINTOLA UNIVERSITY OF TECHNOLOGY, OGBOMOSO

    P.M.B 4000, OGBOMOSO


    STUDENT MEDICAL EXAMINATION OF FITNESS FOR ADMISSION

    Every fresh student is requested to complete part I of this form and report promptly at the University
    Health Centre after securing admission. You will need to pay for, and have your Chest Radiology and
    Medical Laboratory investigation done. Finally, you are to present the Chest X- Ray film and results of the
    Laboratory Test to a Medical Officer at the University Health Centre for completion of form II and III.

    PART I (TO BE FILLED BY THE STUDENT)

    Surname: ……………………………………… Other names: ………………………………………………….


    State of Origin: ……………………………….. Age Next birthday: ……………………………………………
    Sex: ………………………………………….… Marital Status: …….…………………………………………..
    Nationality: .……..……………………….…… Tribe: …………………………………………………………..
    Department: ………………..…………………. Course: ………………………………………………………...

    (A) Would you say your health is Good/Fair/Poor?

    (B) Have you ever been admitted as an in-patient into an hospital? Yes/No: ………
    If Yes, please state reason for admission:………………………………………………………..…..
    ……………………………………………………………………………………………………….…..

    (C) Have you ever visited any hospital for treatment? Yes/No………………………………………………..…
    If Yes, state reason for treatment…………………………………………………………….………..
    ……………..…………………………………………………………………………………………….

    Do you suffer from or have you suffered from any of the following?
    Tuberculosis Yes/ No Nervous Diseases Yes/No
    Schistosomiasis Yes/No Any diseases of the heart ? Yes/No
    Any respiratory Any diseases of
    diseases e.g Bronchia Yes/No genitourinary Yes/No
    Asthma System
    Any diseases of Allergies Yes/No
    digestive system Yes/No
    Any nasal bleeding Yes/No

    If one answer to any of the above is Yes, please give details and Date……………………………………………
    …………………………………………………………………………………………………………………………
    …………………………………………………………………………………………………………………………

    If there are other relevant details of your medical history not covered by the above questions, please
    give particulars……………………….………………………………………………………………………………
    …………………………………………………………………………………………………………………………
    …………………………………………………………………………………………………………………………

    Is your family a healthy one? Yes/No


    Has any member of your family suffered from insanity or mental illnesses? Yes/No
    Have you been immunized against any of the following?

    Tetanus……………………………………………… Date………………………………………………….……
    Yellow Fever………………………………………... Date…………………………………………………….…
    Poliomyelitis………………………………………… Date……………………………………………………….
    Others……………………………………………….. Date…………………………………………………….…
    PART II TO BE COMPLETED BY A MEDICAL OFFICER IN LAUTECH HEALTH CENTRE

    HEIGHT………………………… (METER) WEIGHT……………………………………. (KG)


    Visual Acuity:
    Without Glasses R.6/ L.6/
    Without glasses R.6/ L.6/
    Eyes Ears Circulatory system
    Left Heart
    Right Blood pressure
    Pharynx Respiratory system
    Teeth Lungs
    Lymphatic Glands
    Abdomen
    Liver
    Spleen
    Hernia
    C. N. S
    Pupillary Reflexes
    Spinal Reflexes

    Screening for: Urine: PCV:


    - Hepatitis B PH: Blood Group:
    - Hepatitis C Protein: Genotype:
    - VDRL Glucose
    Nitrite:
    Others

    Date: …………………… Medical Officer (Name)……………………………………..………


    Address: …………………………………………………………...
    ……………………………………………………………
    ……………………………………………………………

    …………………………………
    Signature & date
    Snellens or similar test should be use

    PART III: TO BE COMPLETED BY A MEDICAL OFFICER IN LAUTECH HEALTH CENTRE


    Tuberculin Test (Mantoux with report)
    RVS (Optional):
    Cest X Ray with Radiologist Report

    Remarks: ………………………………………………………………………………………………………….…
    ………………………………………………………………………………………………………………..………..
    …………………………………………………………………………………………………………………..……..
    Final Assessment of Health: ………………………………………………………………………………………..
    ……………………………………………………………………………………………………………………..…..
    …………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………..…..

    ………………………………………… ………………………………
    Date Signature of Medical
    Officer

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