UoEJI/3
P. O. Box 1125 - 30100, Eldoret, Kenya Tel:
+254 53 2063257 /2033712/13 Ext. 2352/3
Mob: 0736 493555; Fax: +254 53 206 3257 E-
mail: [email protected]
Website: www.uoeld.ac.ke
OFFICE OF DEPUTY VICE-CHANCELLOR (ASA)
REGISTRAR ACADEMIC
STUDENTS ENTRANCE MEDICAL EXAMINATION FORM
IMPORTANT
Students are requested to complete part I of this Form, part II should be
completed by the Medical Officer examining the student. The completed form
should be delivered together with other forms on reporting day.
PART I
(a) Full Name:______________________________________________________________
(Surname or last Name) (Other Names)
1. University Admission No. ____________________ Phone No._________________
2. National ID No. /Passport No._______________________ Gender ______________
3. Date of Birth __________________ Place of Birth: _____________________________
4. Full Name of Mother/Father/Guardian ____________________________________
Phone No.__________________ National ID/Passport No.____________________
Address: _______________________________________________________________
5. Give names and address of two persons who can be contacted in case of
an emergency.
Name _____________________________________ Relationship_________________
Phone No.__________________ National ID/Passport No.____________________
Address: _______________________________________________________________
PART II
1. Have you ever been admitted into a hospital?
University of Eldoret is ISO 9001:2015 Certified
________________________________________________________________________
________________________________________________________________________
If so, state reason for admission and date
________________________________________________________________________
2. Have you had any of the following illnesses? (Delete as necessary)
(a) Tuberculosis or other chest infection
Yes
No
(b) Fits, Nervous disease or fainting attacks
Yes
No
(c) Heart Disease or Rheumatic Fever
Yes
No
(d) Any disease of the Digestive System
Yes
No
(e) Allegies to food or drugs
Yes
No
(f) Malaria
Yes
No
(g) Sexuality Transmitted Disease
Yes
No
(h) Poliomyelitis
Yes
No
If the answer to any of the above is yes, please give details with dates
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
If there are any other-relevant details of your medical history not covered by the
above questions, please give particulars.____________________________________
________________________________________________________________________
3. Has any member of your family suffered from:
(a) Tuberculosis
Yes
No
(b) Insanity or mental illness
Yes
No
(c) Diabetes Mellitus
Yes
No
(d) Heart Diseases
Yes
No
(e) Any other Disease
Yes
No
If Yes, kindly give details_________________________________________________
University of Eldoret is ISO 9001:2015 Certified
________________________________________________________________________
________________________________________________________________________
4. Have you been immunized against any of the following diseases?
(a) Small pox
Yes
No
(b) Tetanus
Yes
No
(c) Poliomyelitis
Yes
No
(d) Any other Disease
Yes
No
If Yes, kindly give details _________________________________________________
________________________________________________________________________
________________________________________________________________________
Signature of Student ________________________ Date _______________________
PART III (To be completed by the Examining Medical Officer)
1. Height______________________________Weight __________________________
2. Visual Acuity
Without glasses
With glasses R.6 L.6
3. Hearing Right Ear Left Ear
4. Condition of:
Teeth Throat
Ear Lymphatic glands
Nose
5. Circulatory system:
Pulse Heart
Blood pressure Systolic _______________ Diastolic_________________
6. Respiratory system
University of Eldoret is ISO 9001:2015 Certified
Chest X-Ray (optional depending on Clinical findings)
_______________________________________________________________
7. Abdomen; any palpable masses-physiological or Pathological?
Liver __________________________________________________________
Spleen ________________________________________________________
Uterus ___________________________ L.M.P _______________________
8. Urine: Abbumin _______________________Sugar _________________________
(a) Is the student on any treatment? Yes/No
If Yes, kindly give details__________________________________
_________________________________________________________
(b) Any other observation of importance _____________________________
_______________________________________________________________
_______________________________________________________________
Name of Medical Officer ___________________________________________________
Signature____________________________ Date ________________________________
PART IV
To be completed by University of Eldoret Medical Doctor, after the student has
registered with the University.
Special Remarks____________________________________________________________
Is the student fit for University Education Yes/No ______________________________
Date_______________________________________________________________________
Name of University Medical Officer __________________________________________
Signature _____________________________ Date: ___________________________
University of Eldoret is ISO 9001:2015 Certified
