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    Health Examination Report SECTION 1 (To Be Completed by Candidate) (PART A)

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    Fifi Ain
    This health examination report contains information about a candidate's personal details, medical history, physical examination results, and certification by a doctor. It collects the candidate's full name, contact number, date of birth, gender, marital status, next of kin, and declaration of any medical issues affecting themselves or immediate family. The physical examination section includes measurements, vision and color tests, and assessments of various body systems. The doctor then indicates whether the candidate is in good health or has any complications requiring treatment.

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    Health Examination Report SECTION 1 (To Be Completed by Candidate) (PART A)

    Uploaded by

    Fifi Ain
    34 views5 pages
    This health examination report contains information about a candidate's personal details, medical history, physical examination results, and certification by a doctor. It collects the candidate's full name, contact number, date of birth, gender, marital status, next of kin, and declaration of any medical issues affecting themselves or immediate family. The physical examination section includes measurements, vision and color tests, and assessments of various body systems. The doctor then indicates whether the candidate is in good health or has any complications requiring treatment.

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    medical form

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    medical form

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    This health examination report contains information about a candidate's personal details, medical history, physical examination results, and certification by a doctor. It collects the candidate's full name, contact number, date of birth, gender, marital status, next of kin, and declaration of any medical issues affecting themselves or immediate family. The physical examination section includes measurements, vision and color tests, and assessments of various body systems. The doctor then indicates whether the candidate is in good health or has any complications requiring treatment.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    34 views5 pages

    Health Examination Report SECTION 1 (To Be Completed by Candidate) (PART A)

    Uploaded by

    Fifi Ain
    This health examination report contains information about a candidate's personal details, medical history, physical examination results, and certification by a doctor. It collects the candidate's full name, contact number, date of birth, gender, marital status, next of kin, and declaration of any medical issues affecting themselves or immediate family. The physical examination section includes measurements, vision and color tests, and assessments of various body systems. The doctor then indicates whether the candidate is in good health or has any complications requiring treatment.

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    You are on page 1of 5

    PLEASE USE CAPITAL LETTERS

    HEALTH EXAMINATION REPORT


    SECTION 1 (To be completed by candidate) (PART A)

    FULL NAME: REGISTRATION NO.:

    CONTACT NUMBER: _ DATE OF BIRTH:

    MARITAL STATUS: SINGLE* / MARRIED* GENDER: MALE* / FEMALE*

    NEXT OF KIN :

    NEXT OF KIN’S CONTACT NUMBER:

    NEXT OF KIN’S ADDRESS:

    * Delete whichever not applicable

    1
    SECTION 1
    (PART B) – Please tick ( ) in the relevant box

    Declaration of self and family illness. Explain in full if you or your family have any of the following
    illnesses

    * Immediate family refers to father, mother, brothers / sisters

    IMMEDIATE
    MEDICAL PROBLEMS SELF FAMILY* If “ Yes” please specify

    Yes No Yes No
    1. Congenital or inherited disorder

    2. Allergy
    3. Mental illness
    4. Fits, stroke, other neurological disease
    5. Diabetes
    6. Hypertension
    7. Heart or vascular disease
    8. Asthma
    9. Thyroid disease
    10. Kidney disease
    11. Cancer
    12. Tuberculosis
    13. drug addition
    14. AIDS, HIV
    15. History of surgery
    16. Other illnesses

    Current medication (Long term) (If applicable)

    I hereby certify that the information given above is true. I understand that my application will be rejected
    if there is any false information given.

    Date Signature of tutor

    2
    SECTION 2 – PHYSICAL EXAMINATION
    To be filled by examining doctor

    1. BASIC MEASUREMENT

    HEIGHT : m BLOOD PRESSURE : _


    mmHg

    WEIGHT : kg PULSE RATE : / min

    VISION TEST: Unaided :( R ) (L) COLOUR VISION TEST (including Colour


    Blindness) :
    Aided :( R ) (L)
    NORMAL / ABNORMAL*
    * Additional comment:

    2. GENERAL EXAMINATION

    ITEM YES NO COMMENT


    a. DEFORMITIES
    b. JAUNDICE
    c. OEDEMA
    d. SKIN DISEASES

    3. SYSTEM EXAMINATION

    ITEM NORMAL ABNORMAL COMMENT


    a. EYES(including funduscopy)
    b. EARS
    c. NOSE
    d. ORAL CAVITY / THROAT
    e. NECK
    f. HEART

    g. LUNGS
    h. ABDOMEN
    i. NERVOUS SYSTEM
    j. MENTAL CONDITION
    k. MUSCULOSKELETAL SYSTEM

    3
    SECTION 4 - CERTIFICATION BY THE EXAMINING DOCTOR

    Please tick ( ) in the appropriate box


    I certify that I have on this date examined
    Mr / Ms IC No.
    and found him / her:-

    IN GOOD HEALTH

    HAVING THE FOLLOWING MEDICAL COMPLICATION (S) (Please specify)

    UNDERGOING TREATMENT FOR: (Please specify)

    Signature of Doctor :

    Name of Doctor :
    Date : Address of :
    Hospital/Clinic

    Official stamp :

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