Health Declaration Form
UCOL is a polytechnic under the Education Act.
A declaration of an applicant’s past and present health status is a requirement for entry into this
programme. While health problems are not a barrier to entering a programme, it is important that the
Programme Leader is aware of them and can discuss them fully with you. Please answer all questions
in this section, then make an appointment with your Doctor who should complete the medical
report section.
THE INFORMATION GIVEN WILL BE HELD IN THE STRICTEST CONFIDENCE.
Section A - to be completed by applicant
Family Name First Name(s)
Address
Telephone Number May we approach your Doctor if necessary to do so?
No Yes
If Yes, please give your Doctor’s name and address
Programme applied for
Have you ever suffered form any of the following?
No Yes
1 Back problems
2 Joint problems
3 Foot or leg problems
4 High blood pressure
5 Rheumatic Fever
6 Heart complaint
7 Allergies of any kind
8 Varicose veins
9 Slight defects
10 Head injury
11 Severe or recurrent headaches
12 Epilepsy, fainting attacks, fits or blackouts
13 Diabetes or kidney complaints
14 Asthma, bronchitis, pleurisy or lung disease
15 A substance related disorder, dependence or abuse
16 Mental illness requiring psychiatric care
17 Are you on medication?
18 Other, please specify ___________________________________
Signature of applicant Date
Day Month Year
Section B - to be completed by Doctor
Name of applicant
Are you this person’s regular Doctor?
No Yes
Please list any current or chronic condition(s) which require(s) regular or periodical medical attention and describe any condition/
disability of any nature which may affect successful completion of the programme. (Any previous problems which may recur
should also be noted here.)
Please state medications of any kind which the applicant is currently taking or has taken in the previous three months (excluding
oral contraceptive.)
Name
Address
Signature Date
Day Month Year
Please complete next (attached) page regarding applicant’s immune status.
Section c - to be completed by Doctor
Name of applicant
What is the applicant’s immune status? (If unsure, serology must be checked.)
If no, please Result of serology
Vaccination / If yes, please
Yes (please tick) No (please tick) advise date of Immune /
Immunisation advise date
serology results not immune
Tuberculosis (TB)
N/A N/A
(BCG)
Hepatitis A
Hepatitis B
Hepatitis C (Not
applicable for
nursing students)
Measles
Mumps
Rubella
Chicken Pox
Tetanus N/A N/A
This completed Health Declaration MUST be returned by the doctor to:
Student Registry
UCOL
Private Bag 11022
Palmerston North