medical history & emergency contacts

MEDICAL HISTORY & EMERGENCY CONTACTS – CLASS OF 2015-17
The information provided below will remain confidential and will be accessed and used only in the case of
physical/mental health related issues/emergencies, or as deemed fit by the in-campus Medical/Counselling Centre.
Please disclose all relevant information.
Please Note: A consultation with the in-house doctor is mandatory, within the first 45 days from the date of registration.
Admission No.
Application No.
A
P
U
1
5
P
Programme
G
(Admission number to be filled on registration day)
Name in Full (Block letters)
________________
First Name
Gender
Age
Marital Status
Blood Group
Phone No.:
Email ID:
Emergency Contact person details
(In case this person is not available, the
University will reach out to other contacts
mentioned in the Student information sheet)
Address:
Phone No.:
Email ID:
Address:
Local Guardian at Bangalore (if any)
_________________
Middle Name
_______________
Last Name
CURRENT HEALTH STATUS
1. Are you currently undergoing treatment for any health issues? Please specify

Physical/Mental Health Issues: …………………………………………………….………..………….…………………………….…………………………….………………….
…….……………………….…………………………….……………………….…………………………….……………………….…………………………….…………………………….………….………

Contact details of Physician/Psychiatrist/Therapist: …………………………………………………….………………………….……………………………
……………………….…………………………….……………………….…………………………….…………………………….…………………………….…………………………….………….………

Name of medication (prescribed medicine), if any: ……………………………………………….……………………….……………………………….……
…………………………….………………………….…………………………….…………………………………………………….…………………………….…………………………….………….………
2. Are you allergic to any medication? Please mention the details.
………………………………………….………………………….…………………………………………………….…………………………..….…………………………….………….…………………………….
………………………………………….………………………….…………………………………………………….…………………………..….…………………………….………….…………………………….
PERSONAL MEDICAL HISTORY
3. Have you been treated in the past for any of the below?
 Diabetes
 Hypertension (BP)
 Asthma
 Cardiac diseases
 Any other illness; please specify ……………………………………….…………………………………………………………………………………………...
4. Have you undergone any surgery in the past?
 Yes
 No
If yes, please provide details ………………………………………………………….……………………………………………………………………………………….
…………….…………………………….…..………………………….………….…………………….…………………………….…..………………………….………….…………………….……………………
5. Have you ever suffered from any psychiatric illness?
 Yes
 No
If yes, please provide details ………………………………………………………….……………………………………………………………………………………….
…………….…………………………….…..………………………….………….…………………….…………………………….…..………………………….………….…………………….……………………
FAMILY MEDICAL HISTORY
6. Has any member of your immediate family been treated in the past for any of the below:
 Diabetes
 Hypertension (BP)
 Cardiac diseases
 Psychiatric illness
 Any other illness; please specify ……………………………………………….……………………………………………………………………………………
Place:
Date:
Signature of student
CERTIFICATE OF MEDICAL FITNESS
(TO BE COMPLETED BY A MEDICAL DOCTOR)
Name of student (Block letters)
………………………………………………………………………………………………………………………………………………
Vital signs: Height : ………………………………
Weight : ………………………………
Body Mass Index (BMI) : ……………………………..……
Blood Pressure : …………………….…………… Pulse rate : …………………………..……
Cardiovascular system:
……………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Respiratory system: ……………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Per Abdomen: …………………..…………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Central Nervous System: ……………………………………………………………………………………………………………………………………………………………………………..…
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………...
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
ENT: …………………………………………………………………………………………………………………………………………………………………………………………………………………………..
Vision: ……………………………………………………………………………………………………………………………………………………………………………………………..……………………...
Investigations (if any): ………………………………………………………………………………..……………………………………………………………………………………………………
………………………………………………………………………………………………………………………………….………………………………………………………………………………………………..…
Findings and recommendation:
…………………………………………………………….……………………………………………………………………………………………..……
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
DECLARATION BY DOCTOR
I hereby certify that I have examined ………………………………………………………..…………………………… (Name of student)
………………………………………………..……………………………………………………… and found him/her physically and psychologically
fit to undergo his/her Postgraduate programme.
Place:
Name of Doctor
Date:
(Sign + Seal)