(2 COPIES REQUIRED) MEDICAL FORM -- TMU/JI/6
TOM MBOYA UNIVERSITY
KNOWLEDGE FOR SUSTAINABLE INNOVATION ENTERPRISE
STUDENT MEDICAL FORM
INSTRUCTIONS :
Use CAPITAL LETTERS for clarity and legibility.
Use OFFICIAL NAMES as appear in Identification Documents/Birth Certificate
The Tom Mboya University Medical staff will require the student to submit this medical form, duly filled, as well as duly filled copy of
the Emergency Operation Form, Copy of Identification Documents, and Student Details form
Avoid cutting any form or copy of ID to a smaller size. All documents should be in size A4.
The information provided will only be used to assist the student when need arises.
PART 1 (A):
ADMISSION NUMBER:
(TOM MBOYA UNIVERSITY
ADMISSION NO.)
FULL NAME OF
STUDENT:
DATE OF BIRTH:
(DATE/MONTH/YEAR)
NATIONAL ID. NO. /
BIRTH CERT. NO. / PASSPORT NO.
COUNTY
SUB COUNTY/
CONSTITUENCY
MARITAL STATUS: (Tick) MARRIED [__] SINGLE [__]
STUDENT’S MOBILE
PHONE NUMBERS:
STUDENT’S E-MAIL
ADDRESS
STUDENT POSTAL
ADDRESS
NAME & MOBILE
PHONE NUMBERS OF
GUARDIAN, SPOUSE,
NEXT OF KIN
EMAIL ADDRESSES OF
GUARDIAN, SPOUSE,
NEXT OF KIN
PART 1 (B):
Have you ever been in an in-patient hospital or nursing home? YES/NO. If so, when and for what
complaints?
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
(2 COPIES REQUIRED) MEDICAL FORM -- TMU/JI/6
PART 1 (C):
Have you suffered from or had symptoms of any of the following (Tick as appropriate).
i. Tuberculosis or other chest infection [__] YES / NO [__]
ii. Fits, nervous disease or fainting attacks [__] YES / NO [__]
iii. Heart Disease or Rheumatic fever [__] YES / NO [__]
iv. Any diseases of the digestive system [__] YES / NO [__]
v. Any disease of the Genital-Urinary System [__] YES / NO [__]
vi. Allergies to food or drugs [__] YES / NO [__]
vii. Malaria [__] YES / NO [__]
viii. Sexually Transmitted Disease [__] YES / NO [__]
ix. Poliomyelitis [__] YES / NO [__]
x. Any physical defect or deformity [__] YES / NO [__]
xi. Any disease not mentioned above [__] YES / NO [__]
____________________________________________________________________________________________
____________________________________________________________________________________________
If the answer to any of the above questions is YES, please give more details with dates.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
PART 1 (D):
Is there any other relevant detail about your Medical History not covered by the questions in 1B & 1C
above? (If YES, give details, particulars)
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
PART 1 (E):
Has any member of your family suffered from:
i. Tuberculosis or other chest infection? [__] YES / NO [__]
ii. Insanity or Mental illness? [__] YES / NO [__]
iii. Diabetes Mellitus? [__] YES / NO [__]
iv. Heart Diseases? [__] YES / NO [__]
PART 1 (F):
Have you been immunized against the following diseases?
i. Small pox [__] YES / NO [__] Date______________________________
ii. Tetanus [__] YES / NO [__] Date______________________________
iii. Poliomyelitis [__] YES / NO [__] Date______________________________
STUDENT SIGNATURE:___________________________________ DATE:____________________________
(2 COPIES REQUIRED) MEDICAL FORM -- TMU/JI/6
PART 2 BELOW TO BE FILLED BY AN
EXAMINING MEDICAL OFFICER
PART 2 (A): HEIGHT & WEIGHT
Height ____________________________________ Weight _________________________________
_
PART 2 (B) VISUAL ACUITY:
Without glasses R.6_______________________________ 1.6/_____________________________
With glasses R.6_______________________________ 1.6/_____________________________
PART 2 (C) HEARING:
Right ear ____________________________________________________________________________
Left ear _____________________________________________________________________________
PART 2 (D) CONDITIONS OF:
Teeth ________________________________ Throat _____________________________________
Ears__________________________________ Lymphatic Glands ____________________________
Nose ____________________________________________________________________________
PART 2 (E) CIRCULATORY SYSTEM:
Pulse: ______________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Examining Doctor:
NAME:_____________________________________________________________________________
SIGNATURE:______________________________________ DATE:___________________________________