HOLY CHILD CATHOLIC SECONDARY SCHOOL, ADO-EKITI.

MEDICAL REPORT FORM

(This form should be completed by all new students of the school.)

• PERSONAL DATA (To be filled by the student)

NAME:…………………………………………………………………………………

AGE:……………….      SEX:…………..   DATE OF BIRTH:……………………..

PLACE OF BIRTH:………………………. AGE AT LAST BIRTHDAY…………..

TOWN:……………………………………  LGA:……………………………………

STATE:……………………………………  NATIONALITY:……………………….

MEDICAL HISTORY OF THE STUDENT (To be completed by the Parents)

• Does your child have any childhood illness? Yes/No

If yes state the nature of illness………………………………………............................

…………………………………………………………………………………………..

• Has He/She a known Asthmatic Patient? Yes / No

If yes when was it diagnosed……………………………………………………………

When does He/She have last attack……………………………………………………..

• Has He/She a known sickler? Yes / No
• Any previous admission into Hospital? Yes / No

If yes state the nature of illness:…………………………………………………………

…………………………………………………………………………………………...

• Does He/She on any drug to be taken regularly? Yes / No

If yes state the type(s)……………………………………………………………………

• Has He/She been transfused with blood before? Yes / No

If yes when………………………………………………………………………………

• Does He/She reacts to any drug or food? Yes / No

If yes state the nature…………………………………………………………………….

• Has He/She been operated upon before? Yes / No

If yes state the nature of operation……………………………………………………….

• Did your child receive any immunization?

Tick appropriate

• BCG Yes / No
• Polio Virus Vaccine           Yes / No
• Diphtheria, Pertussis, Tetanus Yes / No
• Measles Yes / No
• Yellow Fever           Yes / No
• Meningitis Yes / No
• Indicate any additional information about your ward that can help to look after Him/Her medically.

……………………………………………………………………………………………

……………………………………………………………………………………………

……………………………………………………………………………………………

……………………………………………………………………………………………

(c) MEDICAL HISTORY AND PHYSICAL EXAMINATION

     (To be completed by the Medical Officer)

• GENERAL EXAMINATION

Eyes                      Normal / Abnormal

Nose                     Normal / Abnormal

Ears                      Normal / Abnormal

Gail                       Normal / Abnormal

 

• VISUAL ACUITY

Right Eye                Without glasses

                               With glasses

Left Eye                  Without glasses

                               With glasses

 

• CARDIO VASCULAR SYSTEM EXAMINATION

BP………………………………….. Pulse rate ……………………………………….

Chest Examination……………………………….……………………………………..

                                            (Comment)

 

Abnormal Examination Hermia / No Hermia

 

• RESULTS OF INVESTIGATION

Blood group………………………………   Genotype……………………………….…

Stool Microscopy…………………………   Urinalysis…………………………...…….

CXR………………………………………   PCV……………………………………….

Hepatitis B & C …………………………    HIV………………………………………..

 

• Medical Officer’s Comments

…………………………………………………………………………………………….

…………………………………………………………………………………………….

…………………………………………………………………………………………….

…………………………………………………………………………………………….