COUNCIL OF LEGAL EDUCATION

NIGERIAN LAW SCHOOL

Medical Centre
BWARI-ABUJA HQS
LAGOS, ENUGU, KANO, YENEGOA AND YOLA CAMPUSES
STUDENT’S PERSONAL DATA
SESSION: Bar PartII 2018/2019 Session

Surname:__________________________________________________________

Other Names:_______________________________________________________

Phone No:__________________________________________________________

Date of Birth:________________________________________________________

Name of Next of Kin:__________________________________________________

Address of Next of Kin:________________________________________________

Next of Kin Phone No:_________________________________________________

Medical Data (to be filled by a Medical Doctor from a Government Hospital)

1. (a) Height_____________ metres (b) Weight ________kg

2. (a) Pulse _____ (b) Blood pressure___________ (c) Respiratory rate _____

3. (a) Heamoglobin estimation: _________________

(b) Genotype: ______________________
(c) Blood group: ____________________
(d) Clotting time: ___________________ _

4. Urine analysis________________________

5. Stool Analysis: _______________________

6. Chest
(a) X-ray (including report) : _______________________
(b) Sputum test for AFB: ___________________________

7. Visual test
rl (with glasses )__________________________________
rl (without glasses) _______________________________

8. (a) HepatitisvBsAg__________________________________
(b) Hepatitis C Virus ________________________________

9. Do you have allergy? If yes, state ___________________________

10. Do you have the following? State yes or no ____________________

(a) Asthma ___________________ (b) Heart Disease ______________
(c) Hypertension ______________ (d) Epilepsy ___________________
 (e) Migraine __________________
(g) Tuberculosis _______________
(i) Blood Disorder______________
(k) Skin Diseases _______________
(m) Physical Defect______________
(o) Peptic Ulcer_________________
(f) Depression _________________
(h) Diabetes___________________
(j) Liver Disease ________________
(l) Syncope ____________________
(n) Others Specify_______________

State reason (if any)

______________________________________________________________________
__________________________________________________________________________________

11.
Have you ever been hospitalized? If yes state Reason(s) ______________________________________
____________________________________________________________________________________

12. Have you ever had blood transfusion? If yes state reason(s)
____________________________________________________________________
__________________________________________________________________________________

13. State any physical, medical or surgical problem (apart from those already listed) that may interfere with
your academic work during your stay in Law School:
_________________________________________________________________________
_____________________________________________________________________________________

14. State the last time you were immunised against the following diseases.
(a) Cerebrospinal meningitis ___________ Yellow Fever ______________

15. Full name and address of government hospital with official stamp.
__________________________________________________________________________________
__________________________________________________________________________________

Signature of Medical Officer ___________________________________________________________

Full name __________________________________________________________________________

Date __________________________________

NB: Read Carefully

(1) The medical data portion of this form is to be completed, signed and stamped by a Medical Practitioner
from a government hospital.

(2) All completed forms duly signed and stamped, should be returned with the following:
(a) Chest X-ray with report
(b) Laboratory Investigation result

(3) Accommodation shall only be given when the above have been complied with.