medical history & emergency contacts

Transcription

medical history & emergency contacts
MEDICAL HISTORY & EMERGENCY CONTACTS – CLASS OF 2015-17
The information provided below will remain confidential and will be accessed and used only in the case of
physical/mental health related issues/emergencies, or as deemed fit by the in-campus Medical/Counselling Centre.
Please disclose all relevant information.
Please Note: A consultation with the in-house doctor is mandatory, within the first 45 days from the date of registration.
Admission No.
Application No.
A
P
U
1
5
P
Programme
G
(Admission number to be filled on registration day)
Name in Full (Block letters)
________________
First Name
Gender
Age
Marital Status
Blood Group
Phone No.:
Email ID:
Emergency Contact person details
(In case this person is not available, the
University will reach out to other contacts
mentioned in the Student information sheet)
Address:
Phone No.:
Email ID:
Address:
Local Guardian at Bangalore (if any)
_________________
Middle Name
_______________
Last Name
CURRENT HEALTH STATUS
1. Are you currently undergoing treatment for any health issues? Please specify

Physical/Mental Health Issues: …………………………………………………….………..………….…………………………….…………………………….………………….
…….……………………….…………………………….……………………….…………………………….……………………….…………………………….…………………………….………….………

Contact details of Physician/Psychiatrist/Therapist: …………………………………………………….………………………….……………………………
……………………….…………………………….……………………….…………………………….…………………………….…………………………….…………………………….………….………

Name of medication (prescribed medicine), if any: ……………………………………………….……………………….……………………………….……
…………………………….………………………….…………………………….…………………………………………………….…………………………….…………………………….………….………
2. Are you allergic to any medication? Please mention the details.
………………………………………….………………………….…………………………………………………….…………………………..….…………………………….………….…………………………….
………………………………………….………………………….…………………………………………………….…………………………..….…………………………….………….…………………………….
PERSONAL MEDICAL HISTORY
3. Have you been treated in the past for any of the below?
 Diabetes
 Hypertension (BP)
 Asthma
 Cardiac diseases
 Any other illness; please specify ……………………………………….…………………………………………………………………………………………...
4. Have you undergone any surgery in the past?
 Yes
 No
If yes, please provide details ………………………………………………………….……………………………………………………………………………………….
…………….…………………………….…..………………………….………….…………………….…………………………….…..………………………….………….…………………….……………………
5. Have you ever suffered from any psychiatric illness?
 Yes
 No
If yes, please provide details ………………………………………………………….……………………………………………………………………………………….
…………….…………………………….…..………………………….………….…………………….…………………………….…..………………………….………….…………………….……………………
FAMILY MEDICAL HISTORY
6. Has any member of your immediate family been treated in the past for any of the below:
 Diabetes
 Hypertension (BP)
 Cardiac diseases
 Psychiatric illness
 Any other illness; please specify ……………………………………………….……………………………………………………………………………………
Place:
Date:
Signature of student
CERTIFICATE OF MEDICAL FITNESS
(TO BE COMPLETED BY A MEDICAL DOCTOR)
Name of student (Block letters)
………………………………………………………………………………………………………………………………………………
Vital signs: Height : ………………………………
Weight : ………………………………
Body Mass Index (BMI) : ……………………………..……
Blood Pressure : …………………….…………… Pulse rate : …………………………..……
Cardiovascular system:
……………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Respiratory system: ……………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Per Abdomen: …………………..…………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Central Nervous System: ……………………………………………………………………………………………………………………………………………………………………………..…
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………...
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
ENT: …………………………………………………………………………………………………………………………………………………………………………………………………………………………..
Vision: ……………………………………………………………………………………………………………………………………………………………………………………………..……………………...
Investigations (if any): ………………………………………………………………………………..……………………………………………………………………………………………………
………………………………………………………………………………………………………………………………….………………………………………………………………………………………………..…
Findings and recommendation:
…………………………………………………………….……………………………………………………………………………………………..……
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
DECLARATION BY DOCTOR
I hereby certify that I have examined ………………………………………………………..…………………………… (Name of student)
………………………………………………..……………………………………………………… and found him/her physically and psychologically
fit to undergo his/her Postgraduate programme.
Place:
Name of Doctor
Date:
(Sign + Seal)

Similar documents

How to Choose The Best Doctor For Back Pain Treatment

How to Choose The Best Doctor For Back Pain Treatment If you've been living with back pain find trusted back pain specialists in your area?Visit paintreatmentspecialists.com, Our goal is to relieve your back pain through best back and spine treatment.

More information