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 ____________
