COLLEGE OF NURSING
CHRISTIAN MEDICAL COLLEGE Name: _______________________
VELLORE – 632 004, Tamil Nadu
***** HT No.:
Preliminary Health Statement
Candidates are instructed to complete this form and send it so that it reaches The Registrar, College of
Nursing, Ida Scudder Road, Vellore – 632 004, Tamil Nadu. To supplement this Preliminary statement, a
physical examination, relevant blood and urine tests will be done when you appear for the interview at
Vellore. The blood tests will include screening for blood borne viruses (Hepatitis B, Hepatitis C and HIV)
Age Sex Height Weight
(in years) (Male/female) (in cms) (in kgs)
Read through the following questions CAREFULLY and answer by circling either “YES” or “NO”
1. Can you read without glasses? Yes No
2. Do you have frequent sneezing/ running nose? Yes No
3. Do you have frequent bleeding from nose? Yes No
4. Do you have decreased hearing? Yes No
5. Do you have discharge from the ear? Yes No
6. Do you have frequent cough? Yes No
7. Do you have frequent wheezing attacks? Yes No
8. Have you coughed blood in sputum? Yes No
9. Do you have chest pain? Yes No
10. Do you have breathing difficulty? Yes No
11. Do you tire easily? Yes No
12. Do you have palpitations (heart beating fast)? Yes No
13. Do you have swelling of your feet or legs? Yes No
14. Do you have frequent loose motions (diarrhoea)? Yes No
15. Do you have recurrent abdominal pain? Yes No
16. Do you urinate frequently? Yes No
17. Do you have pain or burning while passing urine? Yes No
18. Do you have joint pain? Yes No
19. Do you get back pain while standing for a long time? Yes No
20. Have you lost interest in eating food? Yes No
21. Do you have difficulty in falling asleep? Yes No
22. Do you have frequent headaches? Yes No
23. Do you have fainting attacks? Yes No
24. Have you ever lost consciousness? Yes No
25. Do you have any skin disease? Yes No
26. Are you allergic to any medicines? Yes No
For Female Candidates
27 Do you have a breast lump? Yes No
28 Do you have regular menstrual periods? Yes No
29 Do you have any problems related to menstruation? Yes No
30 Are you able to carryout normal activities during menstrual periods? Yes No
31 Mention the date of your last menstrual period (dd/mm/yy)
Past history of illness:
If you have been diagnosed to have any of the following disease (past or present), write “Yes” in the box
provided against the condition:
1. Diabetes 5. Hypertension 9. Heart disease
2. Jaundice 6. Kidney disease 10. Peptic ulcer
3. Tuberculosis 7. Leprosy 11. Rheumatic fever
4. Seizure (fits) 8. Mental illness 12. Bronchial asthma
Any other medical illness (specify):
Any surgeries (specify):
Family Health Record:
Has anyone in your family suffered / is suffering from any of the following disease?
[Family members: Father, mother, brother, sister, grand parents, uncle, aunt]
Disease Relation
1. Diabetes mellitus Yes No
2. Hypertension Yes No
3. Tuberculosis Yes No
4. Mental illness Yes No
5. Any other illness (Specify)
Statement of present Health: (Circle the statement that is applicable)
1. To my knowledge, I have no illness or deformity at this time.
2. I have the following conditions which are not interfering with my studies.
_________________________________________________________
[Note: If you have myopia of more than 7 diopters, you should bring the prescription for your glasses for the
last 3 years.]
Have you visited CMC, Vellore or any of its peripheral hospitals (Schell, MHC, CHAD, RUHSA) in the
past for treatment: If yes give your Hospital number _______________
If you are undergoing treatment for any illness currently, please bring your old treatment and
investigation records.
I have gone through the information provided in this sheet and given my consent for all the tests
mentioned. If any significant abnormality is found on the health check-up, I AM WILLING /
NOT WILLING to be counseled about this in confidence by the convenor of the medical board.
Falsification / hiding any information given above will lead to
disqualification from the selection process
_____________________
Signature of the Candidate Countersigned by the Parent / Guardian
Place: _________________
Date: