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Medical Data Collection Form
Trinity University Medical Record
Name: *
Date of birth: *
MM
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DD
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YYYY
Gender: *
Department: *
Genotype: *
What is your Blood Group? If your choice is others, ensure you visit the clinic on campus to register the blood group with the nurse on duty. *
Do you have any allergies? *
If yes, what are you allergic to? *
Do you have any pre- existing medical condition *
Mention any medical condition you have: *
Have you had any surgeries before? *
If yes, what kind of surgeries and when did you have them? *
What common illness(es) have you had from childhood? *
Write a brief medical history of yourself. *
Parents Email Address *
Parents Phone number *
A copy of your responses will be emailed to the address you provided.
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