TUMAINI UNIVERSITY MAKUMIRA KILIMANJARO CHRISTIAN MEDICAL UNIVERISTY COLLEGE All correspondences should be Addressed to the Provost P. O. Box 2240, MOSHI, Tanzania Telephone 255-027-2753616 Fax: 255-027-2751351 Email : admission@kcmuco.ac.tz Web page: http://www.kcmuco.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 Any loss of consciousness? Yes / No Herpes Zoster Yes / No If yes, dates of incident____________________ If yes, date of illness ___________________________ Current treatment ____________________ Part of body affected ___________________________ Any neurological deficiency? Yes / No Hypertension Yes / No If yes, state deficiency ____________________ If yes, when detected __________________________ When acquired ____________________ Current treatment ___________________________ Current treatment ____________________ Asthma Yes / No Any fits? Yes/No If yes, when detected ___________________________ If yes, type of fits ____________________ Current treatment ___________________________ Date of last episode ____________________ Allergies Yes / No Current treatment ____________________ If yes, date of last reaction _______________________ 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 _____________ 1 SECTION B (TO BE COMPLETED BY A REGISTERED MEDICAL OFFICER OR DOCTOR) IV. VARIOUS TESTS (I) GENERAL APPEARANCE (II) CARDIO-RESPIRATORY SYSTEM (CHEST X-RAY FILM & REPORT ARE NEEDED) Height _____________Weight _____________ Blood Pressure _______ Pulse Rate ________ Lung Fields __________Breast Lumps __________ Lymphnode Palpable ____________________ Heart Size __________ Heart Sounds __________ (III) ABDOMINAL EXAMINATION Skin Appearance ______ _________________ (ABDOMINAL U.S.S. REPORT IS NEEDED. IF MASS Throat Tonsils __________________________ 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 (I) BIOCHEMICAL (III) HEMATOLOGY Fasting Blood Sugar ______________________ (CULTA COUNTER) Serum Creatinine ______________________ Haemoglobin _________ ____________________ Serum Aspartate T. ______________________ White Cells Count __________________________ Serum Alanine T. _______________________ (IV) PARASITOLOGY Blood Urea _______________________ Stool Routine Examination ___________________ Uric Acid _______________________ Treatment_________________________________ (II) IMMUNOLOGY Urinalysis & Sediment Microscopy 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 _______________ . 2