HTTP/1.0 200 OK Cache-Control: no-cache, private Date: Mon, 19 Sep 2022 07:11:27 GMT 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 Page 1 of 2 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: Page 2 of 2