THE FEDERAL POLYTECHNIC NASARAWA,NASARAWA, NIGERIA
MEDICAL EXAMINATION FORM
ADMISSION DATE: 2013-01-14
MEDICAL EXAMINATION FORM (THIS MEDICAL REPORT FORM MUST BE COMPLETED BY NEWLY ADMITTED STUDENTS)
SECTION A: (TO BE COMPLETED BY THE STUDENT)
NAME (in full) : DATE OF BIRTH : SEX: UKPO YUSUF OKAH
TELEPHONE MARITAL STATUS LAST OCCUPATION NAME AND ADDRESS OF PARENT/GUARDIAN PHONE PREVIOUS MEDICAL HISTORY
Previous Illness: Date of Illness: 1. Childhood 2. Adult Previous Operation: Date of Operation:
Previous Injuries Date of Injuries:
VACCINATION WITH DATES
Smallpox Triple Vaccine (DDT) Polio Miletus
Typhoid Yellow Fever Meningococcus Meningitis
*Do you suffer from any other personal health defect e.g Sight, Hearing impairment and whether or not adequately? ________________________________________
*Was it corrected? ___________________________________________________
*Have you been treated for Nerve or Mental Illness__________________________
*How would you rate your own health status? (poor, fair, good, excellent)
HAVE YOU SUFFERED FROM OR DO YOU SUFFER FROM ANY OF THE FOLLOWING
Tuberculosis Yes No Heat in the Head or Body Yes No Sickle Cell Anemia Yes No
Hypertension Yes No Diabetes Yes No Hard Disease Yes No
Epilepsy Yes No Peptic Ulcer Yes No Gonorrhea or Syphilis Yes No
Mental Illness Yes No Pile(Heamorrhoid) Yes No Asthma Yes No
I, UKPO YUSUF OKAH hereby certify that to the best of my knowledge and belief, that the information given as above are correct.
Student Signature with Date______________________________
SECTION B: (TO BE COMPLETED BY THE STUDENT)
NAME (in full) : DATE OF BIRTH : SEX: UKPO YUSUF OKAH
TELEPHONE MARITAL STATUS LAST OCCUPATION NAME AND ADDRESS OF PARENT/GUARDIAN PHONE PREVIOUS MEDICAL HISTORY
Previous Illness: Date of Illness: 1. Childhood 2. Adult Previous Operation: Date of Operation:
Previous Injuries Date of Injuries:
VACCINATION WITH DATES
Smallpox Triple Vaccine (DDT) Polio Miletus
Typhoid Yellow Fever Meningococcus Meningitis
*Do you suffer from any other personal health defect e.g Sight, Hearing impairment and whether or not adequately? ________________________________________
*Was it corrected? ___________________________________________________
*Have you been treated for Nerve or Mental Illness__________________________
*How would you rate your own health status? (poor, fair, good, excellent)
HAVE YOU SUFFERED FROM OR DO YOU SUFFER FROM ANY OF THE FOLLOWING
Tuberculosis Yes No Heat in the Head or Body Yes No Sickle Cell Anemia Yes No
Hypertension Yes No Diabetes Yes No Hard Disease Yes No
Epilepsy Yes No Peptic Ulcer Yes No Gonorrhea or Syphilis Yes No
Mental Illness Yes No Pile(Heamorrhoid) Yes No Asthma Yes No
I, UKPO YUSUF OKAH hereby certify that to the best of my knowledge and belief, that the information given as above are correct.
Student Signature with Date______________________________
SECTION B: (TO BE FILLED BY THE MEDICAL OFFICER AT THE POLYTECHNIC’S MEDICAL CENTER)
1. Physical Examination
Height Weight Central Nervous System
Respiratory System
E.N.T Cardiovascular System: Pulse Heart Sound B.P Apex Beat
G.I.T Gastro-intestinal System: Teeth Liver Spleen Other Mass
Genito-Urinary System Musculo-Skeletal System
Skin and Integument Special Sense Eye-Vision R L Without Glasses
R L With Glasses 2. Laboratory Examination
(a) Blood Hb Sickling Test (b) Blood Group (c ) Urine:
Sugar, Protein & Microscopy (d ) Stool:
Microscopy
3. Special Senses
X-ray (Chest) required routinely: 4. Assessment of Mental Health
5. Treatment Administered
COMMENT & RECOMMENDATION:
Name of Medical Officer:____________________________________________ Signature of Medical Officer:_________________________________________ 