TUKJ 003
THE TECHNICAL UNIVERSITY OF KENYA
STUDENT ENTRANCE MEDICAL EXAMINATION
REGISTRATION NO: ……………………………………………………………………………………………………
IMPORTANT:
It is a UNIVERSITY requirement that all the students joining the UNIVERSITY must complete part I of
this form. Thereafter he/she must complete part II with assistance of a qualified and registered
Doctor or Clinical Officer) from a Government/Mission Health Facility or from a private Hospital
(Not private clinic nor private health Centre). Part III will be filled by the examining Doctor or
Clinician who will thereafter print on the form his full name and Professional Registration Number
PART I
SURNAME…………………………………. OTHER NAMES………………………………………. GENDER……………
DATE OF BIRTH…………………………PLACE OF BIRTH……………………………………………………………….
NATIONALITY……………………………MARITAL STATUS……………NO. OF CHILDREN……………………
NAME OF PARENT/GUARDIAN/NEXT OF KIN……………………………………………………………………….
POSTAL ADDRESS……………………………………………………………………………..………………………………….
TELEPHONE NO. (HOME)……………………………………………………………………………………………………..
STUDENT MOBILE NUMBER…………………………………………………………………………………………………
NHIF Membership No (Self, Parent, Guardian) …………………………………………………………………….
PART II (To be completed by the student with the Doctor’s/Clinician’s help)
Have you ever been admitted into hospital? ..........................................................................................................
If so when and for what illness? ...................................................................................................................................
Have you ever suffered from any of the following? ..................................................................................................
Allergy YES/NO Infection mononucleosis YES/NO
Anaemia YES/NO Jaundice/Hepatitis YES/NO
Asthma YES/NO Peptic Ulcer YES/NO
Orthopedic Problems YES/NO Mental illness YES/NO
Bilharzia YES/NO Poliomyelitis YES/NO
Bladder problem YES/NO Severe headaches YES/NO
Chest infections YES/NO Surgery YES/NO
Epilepsy YES/NO Thyroid disease YES/NO
Diabetes mellitus YES/NO Tuberculosis YES/NO
Eye problem YES/NO Speech problem YES/NO
Heart disease YES/NO Hearing problem YES/NO
TUKJ 003
High blood pressure YES/NO Sexually transmitted disease YES/NO
Blood transfusion YES/NO Menstrual disturbances YES/NO
HIV infection YES/NO Are you an any treatment now YES/NO
Other frequent
diseases/Conditions not YES/NO
mentioned above
If the answer to any of the above is YES, please give details………………………………………………………..
………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………….
Where are you getting treatment, and who’s your doctor/Clinician?
.............................................................................................................................................................
Do you have any other medical insurance cover (if yes specify the name, number, principal
member and details of cover) ………………………….....................................................
FAMILY MEDICAL HISTORY
Has any member of your family suffered from any of the following?
Diabetes mellitus YES/ Heart disease YES/
NO NO
Bronchial asthma YES/ High blood pressure YES/
NO NO
Mental illness YES/ Sickle cell disease YES/
NO NO
Other Chronic/Congenital
disease or condition
AUTHORIZATION STATEMENT
I hereby authorize any Doctor, clinician, health facility, medical provider, any insurance company or
any company, institution any other person who has any record or information about me and/or any
of my family members to provide TECHNICAL UNIVERSITY OF KENYA with complete information
including copies of their records with reference to my sickness or accident, any treatment,
examination, advice or hospitalization. Any photocopy of this authorization shall be regarded as an
original copy.
STUDENTS SIGNATURE………………………………………………………..……………………………. DATE…………………..
PART III: (To be completed by the Examining Doctor/Clinician)
Immunization record……………………………………………………………………………………………………
Height……………………………………………. Weight…………………..Any deformity…………………………
Visual Acuity……………………………………LE 6……………………….RE 6…………………………..……………
Hearing………………………………………..Nose……………………….Throat………………………..……………
Lymphatic glands…………………………………………………………………………………………………………..
CARDIOVASCULAR SYSTEM
TUKJ 003
Pulse…………………………………………/Minute Heart sounds…………………………………………..
Regular/irregular………………………….. Blood pressure…………………………….
RESPIRATORY SYSTEM:
Clinical findings………………………………………………. Respiratory Rate…………………………………
Percussion………………………………………………………...Auscultation…………………………………..
CXR, X-Ray and report should be submitted together with the form.
ALIMENTARY SYSTEM
Teeth……………………………. Tongue………………………………Abdomen………………………………
GENITO-URINARY SYSTEM
Urethral discharge……………………………. L.M. P…………………………. Uterus……………………………
Deposit……………………………………………………………………………………………………………….
HIV test………………………………………………………………………………………………………………
OTHER SYSTEMIC EXAMINATION/FINDINGS
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………..
OTHER TESTS RECOMMENDED BY EXAMINING DOCTOR/CLINICIAN, and the Test Results
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………….
COMMENTS BY THE EXAMINING DOCTOR/CLINICIAN
……………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………….
Doctor’s/Clinician’s name (Printed)…………………………………………. SIGNATURE and
STAMP………………………………………………………………………………………………………..………………………………..
Professional Registration Number ………………….…………………………DATE………………………………………..
