MB ChB 2016 Cohort
Additional Information for Clinical Skills Training
A condition of your registration at Warwick Medical School is that you inform us of anything that has
in the past or currently affects your ability to learn, or may influence your performance during the
course, including interacting with patients. Returning this completed form will allow Warwick Medical
School to instigate any necessary support systems.
You need to consider the following:

Vision – do you have sufficient vision to be able to pass the driving test visual requirement, and
read handwritten and typed text, placed at an appropriate distance, without visual aids other than
spectacles or contact lenses, and that you can understand the word.

Specific Learning Difficulty (SpLD) – such as dyslexia or dyscalculia must be declared. The
University will make an assessment of any declared SpLD and if deemed necessary appropriate
help can be organised.

Hearing – that you are able to hear, using a fitted hearing aid if required, such that you can
understand a softly spoken child or elderly patient, and that you can hear what is said when using
a conventional telephone.

Fit or seizure – have you experienced either in the last year.

Are you physically able to write legibly by hand.

Do you have a physical disability that is likely to prevent you from successfully completing training
on how to attend to a patient who has collapsed to the floor, which requires you to turn the patient
into a safe position.

Blood borne viruses – if you do not acquire the necessary immunity you may still be admitted to
study but be excluded from exposure prone procedures.

Other problems e.g. allergies, diabetes, depression
Do you have any of the conditions above?
YES / NO
Do you have any other condition affecting your physical or mental health
which may require additional learning support to be put in place?
YES / NO
Do you have a current or spent criminal conviction(s) and/or caution(s)
contained in a DBS check?
YES / NO
If YES to any please give details below:
I declare that the above information is true and complete to the best of my knowledge and
belief. I agree that if I accept a place to study at Warwick Medical School that I may be invited
to attend a medical assessment by an Occupational Health Advisor / Physician.
Surname:
First Name:
UCAS Number:
University Number:
Signature:
Date:
Please return to: Mrs Ann Malczewski, Medical Teaching Centre,
University of Warwick, Coventry, CV4 7AL by 31 May 2016.