Royal College of Surgeons in Ireland
Medical University of Bahrain
PO Box 15503, Adliya Kingdom of Bahrain
Tel: + 973 17351450 Fax: + 973 17330806
Website: www.rcsibahrain.edu.bh
CONFIDENTIAL MEDICAL REPORT
OF APPLICANT FOR ADMISSION TO
SCHOOL OF NURSING AND MIDWIFERY
SCHOOL OF MEDICINE
Dear Doctor: Please complete this form and return in a sealed envelope marked "Confidential" to: Admissions
Officer, RCSI Bahrain
Name of Applicant (in Block Capitals): _______________________________________________________________
Address: ______________________________________________________________________________________
Doctor’s Name (in Block Capitals): __________________________________________________________________
Address: _______________________________________________________________________________________
Contact Numbers: _______________________________________________________________________________
The Physician/General Practitioner is kindly requested to answer the following questions.
1
2
3
4
5
6
7
8
How long have you known the applicant? __________________________________________________________
Is there a significant history of mental illness? If yes, please give all known details. __________________________
Is there a significant history of physical illness? If yes, please give all known details. _________________________
Is the applicant taking any medication at present? If yes, please give all known details. ______________________
Does the applicant have a past or present history of substance abuse? If yes, please give all known details. _____
On clinical examination, is there any evidence of mental or physical illness? If yes, please give details. _________
Does the applicant suffer from any visual, hearing or learning disabilities? If yes, please give details. ___________
Does the applicant have any problems which, in your opinion, might interfere with his/her ability to complete the
studies and examinations required to qualify in medicine/nursing? _____________________________________
The Ministry of Health of Bahrain issued the Policy for Immunization and Infectious Diseases Screening for Medical,
Dental, Nursing and Physiotherapy students requiring immunization and must be tested negative for infectious
disease.
Kindly indicate the result of the following Blood Borne Diseases:
1. Hepatitis B
Positive
Negative
2. Hepatitis C
Positive
Negative
3. HIV
Positive
Negative
st
4. Tuberculosis
Positive
Negative (TB require 1 step Tuberculin Skin Test and x-ray)
Students accepted to the University will be required to obtain a confirmatory blood test for Blood Borne Diseases
before joining the University. Therefore, a repeat of the above mentioned test will be conducted during
Orientation Week. If a positive result is received, a student will not be eligible for joining the program and non
Bahraini student will be repatriated as mandated by Ministry of Health of Bahrain. It is to the applicant’s advantage
to be tested prior to accepting a place.
NOTE: Tuberculosis screening will include a two-step Tuberculin Skin Test (TST) and chest x-ray
All students must complete the required immunizations before joining the College. Kindly indicate if the applicant had
been immunized against:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Hepatitis A
Hepatitis B
Typhoid
Diphtheria (TD)
Influenza (Flu)
Measles
Mumps
Rubella
Polio
YES
NO
YES (kindly include antibody titre)
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
NO
NOTE: Incomplete immunization can be completed in Bahrain. Furthermore, all students are required to
participate in the immunization programme of the University.
Please attach the laboratory result of the Blood Borne Diseases and the copy of the immunization record.
If you wish to provide additional information or expand on any of the questions above, please attach a separate sheet.
You may also contact the Admissions Office directly on the numbers above.
Doctor’s Signature: ................................................................
Date: ……………………………………………
Date and stamp:
OFFICIAL STAMP