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FORM C: MEDICAL EXAMINATION FOR
2022-2023 ADMISSION
The Deputy Vice Chancellor Academic Affairs
Ardhi University
P.O Box 35176
DAR ES SALAAM
SURNAME
........................................................
AGE ...........................
SEX .............................
FIRST NAME
...................................................
OTHER NAME
..............................................
SCHOOL
...............................................................
DEGREE PROGRAMME ....................................................................................
MARITAL STATUS ................................
A. PERSONAL HISTORY (To be completed by the applicant)
1. Have you ever suffered from any serious diseases or disorders? (YES* / NO*)
If YES, explain
2. Are you suffering from or having any medical conditions/disabilities/disorders that require
necessary attention? (YES*/ NO*)
If YES, explain
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I .................................................................................... declare that the information provided above is correct.
Date ......................................................... Signature ..........................................
B. PYSICAL EXAMINATION (To be completed by registered medical practitioner)
1. General Examination
Weight ..................Height .......... Blood Pressure (BP) ............. Pulse rate ................ SPO2
..................
2. Systemic Examination
1. Central Nervous System (CNS) ..........................................
2. Respiratory System (Attach evidence e.g., Chest x-ray for Tuberculosis)
.................................................................
3. Cardiovascular System (CNS) ..........................................
4. Gastrointestinal System (GIS) ..........................................
5. Genital Urinary System (GUS) ..........................................
6. Gynecological System ..........................................
7. Musculoskeletal System (MSS) ..........................................
8. Others if any (Specify) ..........................................
3. Investigations, (Please Specify if Necessary and Attach Results)
1.
2.
3.
C. CONCLUSION
I have examined Mr./Miss / Mrs .................................................... and consider that he*/she* is
physically and mentally fit*/not fit* to be admitted to the University for higher studies.
Name of the examining Medical Practitioner
....................................................................................................
Title ...............................................................................................
Qualification .......................................................................................
Signature ........................................ Date ................................................
Official Stamp:
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