Anda di halaman 1dari 2

TUMAINI UNIVERSITY

KILIMANJARO CHRISTIAN MEDICAL COLLEGE


All correspondences should be
Addressed to the Provost

P. O. Box 2240, MOSHI, Tanzania


Telephone 255-027-2754377/ 83 Ext 443
Fax: 255-027-2751351
Email : psec@kcmc.ac.tz
Web page: http://www.kcmc.ac.tz

MEDICAL EXAMINATION FORM


This form consists of Section A to be completed by the applicant and Section B to be completed by a
registered medical officer or doctor. The completed form must be submitted along with all the other
application materials.
SECTION A
(TO BE COMPLETED BY THE APPLICANT)
[Please Write in Block Letters] I. PERSONAL INFORMATION
First:
Middle:
Last:
Marital Status
Full Name
Date of Birth
Degree Programme
Gender
II. PAST MEDICAL HISTORY
(I) NERVOUS SYSTEM
Herpes Zoster Yes / No
Any loss of consciousness? Yes / No
If yes, date of illness ___________________________
If yes, dates of incident____________________
Part of body affected ___________________________
Current treatment
____________________
Hypertension Yes / No
Any neurological deficiency? Yes / No
If yes, when detected __________________________
If yes, state deficiency ____________________
Current treatment
___________________________
When acquired
____________________
Asthma Yes / No
Current treatment
____________________
If yes, when detected ___________________________
Any fits? Yes/No
Current treatment
___________________________
If yes, type of fits
____________________
Allergies Yes / No
Date of last episode ____________________
If yes, date of last reaction _______________________
Current treatment
____________________
Cause of reaction
___________________________
Major Surgeries Yes / No
(II) MUSCULO-SKELETAL SYSTEM
If yes, type of surgery ___________________________
Any Deformity? Yes / No
Date of surgery
___________________________
If yes, which part of the body ______________
Outcome of surgery ___________________________
When acquired
____________________
Any Heart Disease Yes / No
Use of accessories or aids _________________
If yes, what disease? ___________________________
Current Treatment
___________________________
(III) OTHER CHRONIC CONDITIONS
Any Dietary Restrictions Yes / No
Diabetes Mellitus Yes / No
If yes, state restriction ___________________________
If yes, when detected ____________________
______________________________________________
Current Status
____________________
Tuberculosis Yes / No
Please Note: The applicant is responsible for
If yes, when detected ____________________
maintaining any dietary restrictions.
Current status
Cured / On going treatment
III. DECLARATION
I declare that all the information provided herein is true to the best of my knowledge.
Signature ______________________________________ Date _____________

SECTION B
(TO BE COMPLETED BY A REGISTERED MEDICAL OFFICER OR DOCTOR)
IV. VARIOUS TESTS
(I) GENERAL APPEARANCE
(II) CARDIO-RESPIRATORY SYSTEM
Height _____________Weight _____________
(CHEST X-RAY FILM & REPORT ARE NEEDED)
Lung Fields __________Breast Lumps __________
Blood Pressure _______ Pulse Rate ________
Heart Size __________ Heart Sounds __________
Lymphnode Palpable ____________________
Skin Appearance ______ _________________
(III) ABDOMINAL EXAMINATION
Throat Tonsils __________________________
(ABDOMINAL U.S.S. REPORT IS NEEDED. IF MASS
DETECTED
Teeth Dentition _________ Carious _________
FILM IS NEEDED)
EARS:
Contour: Sunken / Normal / Distended
Rt Hearing _______ Drum Membrane _______
Skin Scar ________________________
Lt Hearing _______ Drum Membrane ________
Umbilicus _____________ Hernia ______________
EYES:
(IV) MUSCULO SKELETAL SYSTEM
Rt VA __________ Squint __________
Any
Deformation? Yes / No
Lt VA ___________ Squint __________
If yes which part of the body __________________
Type of deformity ___________________________
V. LABORATORY INVESTIGATIONS
(III) HEMATOLOGY
(I) BIOCHEMICAL
Fasting Blood Sugar ______________________ (CULTA COUNTER)
Haemoglobin _________ ____________________
Serum Creatinine ______________________
White Cells Count __________________________
Serum Aspartate T. ______________________
Serum Alanine T. _______________________ (IV) PARASITOLOGY
Blood Urea
_______________________ Stool Routine Examination ___________________
Uric Acid
_______________________ Treatment_________________________________
Urinalysis & Sediment Microscopy
(II) IMMUNOLOGY
VDRL Reaction if +ve treatment______________ ______________
Widal Reaction if +ve treatment______________ Treatment ________________________________
Contact with Human Immunodeficiency Virus
Blood Smear for Protozoa, Hemoflagellates &
Sero conversion (Optional) _________________ Spirochaetae ______________________________
Treatment ________________________________
VI. OTHER OBSERVATIONS
Any other observations whether irritable or aggressive:

VII. DECLARATION

I Dr. ______________________________ of _____________________has examined the named


candidate and conclude that the candidate is / is not suitable to attend a Diploma or Degree programme
at Kilimanjaro Christian Medical College of Tumaini University.
Signature with Official Stamp ___________________________Date _______________