CONFIDENTIAL MEDICAL REPORT
The information provided about your medical history is to ensure appropriate care and personal safety to assist in the case of any medical emergency whilst in the University. The information provided will be kept strictly confidential. Please indicate whether you have ever suffered from or been informed of the following?
BIO DATA
Student number (9 digits) *
Applicant ID (7 digits starting with UEW) *
Firstname *
Middlename
Lastname *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Primary phone number *
Secondary phone number
email *
Campus *
Faculty *
Programme *
Medical History Question
Depression or other psychiatric illness *
Fits, convulsion, blackout or faint spells *
Sickle cell disease/complications *
Liver disease(Jaundice, hepatitis) *
Chronic cough(Tuberculosis) *
Recurrent chronic epigastric pain (Peptic ulcer) *
Diabetes (sugar in urine) *
Heart problems or high blood pressure (sustained) *
Allergies to medicines, substance, foods *
Kidney disease *
Any surgical operation (specify dates) *
Recurrent sexually transmitted disease *
Excessive menstrual bleeding (not applicable)
Clear selection
Recurrent vaginal discharge (not applicable)
Clear selection
Breast lumps (not applicable)
Clear selection
State the last normal menstrual period (not applicable)
Clear selection
Do you smoke regularly? *
Do you consume large volumes of alcohol (>1 glass full) *
Are you finding it difficult to stop smoking? *
Are you finding it difficult to stop alcohol intake? *
Are you on a prolonged (regular) medication, (specify) *
Any other illness or infectious diseases *
Bronchitis, asthma or other chest conditions *
Bone or joint disease *
Blood transfusion (specify dates) *
I hereby certify that the information I have given in this form is in every respect true and correct *
Required
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