2013 UNIVERSITY HEALTH SERVICE 47 Park Place, Cardiff CF10 3AT Email health@cardiff.ac.uk This information is governed by NHS Medical Information Guidelines and is not accessible to non-Health Centre Staff.

All new students must complete this form and email it to the University Health Centre at the address above.
All students are invited to discuss health problems with Health Service medical staff and are encouraged to seek early advice on matters concerning health. This form will help in providing the medical background of each student on commencing university. YOU ARE REMINDED THAT IT IS ESSENTIAL TO REGISTER WITH A LOCAL GENERAL PRACTITIONER WHEN YOU ARRIVE IN CARDIFF. LISTS OF PRACTICES ARE AVAILABLE FROM THE UNIVERSITY HEALTH SERVICE, STUDENT SERVICES' OFFICE, THE WELFARE OFFICE IN THE STUDENTS’ UNION AND FROM THE HALLS OF RESIDENCE. Surname: Title: Mr/ Mrs/ Ms/ Miss

Forenames:

Place a cross alongside the student group which applies to you: Undergraduate ERASMUS Postgraduate

Home Address:
Term Address
(hall, student house or private accommodation)

Telephone:
Telephone:
Mobile phone:

Date of Birth:
Department/ School:

Have you been an undergraduate at Cardiff University?
No Yes
If yes, what year:

Doctor with whom you are registered at home:

Name:

Address:

Have you ever had any of the following illnesses?
Please tick box Please provide further details where necessary Ear Conditions/Deafness