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Last Name

Other Names

Student Identity No

Date Of Birth

Have You Been Hospitalized Before?

If YES State Where You Where Hospitalized

If YES State Why You Where Hospitalized

If YES State When You Where Hospitalized

Have You Had Accident Before?

If YES State The Type Of Accident

If YES State Why You Had The Accident

If YES State When You Had The Accident And How Long You Were Hospitalized

Have You Had X-ray Before?

If YES State The Type Of X-ray

If YES State Why You Had The X-ray

If YES State When You Had The Xray

Are You Allergic To Any Drug?

Select Your Allergy For Each Drug And State The Type Of Reaction.

Chloroquine

Maloxine

Fansidar

Metakelfin

Penicillin

Paracetamol

Please Specify Any Other Drug You Are Allergic To

Have You In The Past Suffered From Any The Following Ailment(Tuberculosis,Epilepsy/Convulsions,Measles,Asthma,Chickenpox,Diabetes,Hypertension,Ulcer)?

If YES , Indicate The Ailment And Date.

Tuberculosis

Epilepsy/Convulsion

Measles

Asthma

Chickenpox

Diabetes

Hypertension

Ulcer

Have You Ever Coughed Out Blood?

Have You Ever Vomited Blood?

Have You Had Any Immunization In The Past?

Have You Had Any Surgery/operation?

Is Your Sight Good?

When Did You Start-using Glasses




Type Of Glasses You Are Using

Do You Have Any Physical Disability?