BAHAMAS TECHNICAL & VOCATIONAL INSTITUTE
MEDICAL RECORD
Please return this form dated, signed and stamped from a Medical Doctor in a sealed envelope marked
`MEDICAL RECORD’ To: THE ADMISSIONS OFFICE, BAHAMAS TECHNICAL & VOCATIONAL
INSTITUTE.
PART A: GENERAL INFORMATION
TO BE COMPLETED BY APPLICANT, APPLICANT’S PARENT OR GUARDIAN
______________________________________________________________________________________________________________________________
LAST NAME FIRST NAME MIDDLE NAME
______________________________________________________________________________________________________________________________
ADDRESS (Street Name) HOUSE#
______________________________________________________________________________________________________________________________
P.O. BOX TELEPHONE: (HOME) (WORK)
DATE OF BIRTH:_____/_____/_____ AGE:_________ SEX: MALE FEMALE
STUDENT NUMBER:________________ SEMESTER:____________ YEAR ENTERING BTVI__________
MARITAL STATUS: MARRIED SINGLE
___________________________________________________________________________________________________________________________
PERSON TO NOTIFY IN CASE OF EMERGENCY RELATIONSAHIP
___________________________________________________________________________________________________________________________
STREET ADDRESS TELEPHONE: (HOME) (WORK)
FAMILY MEDICAL HISTORY
Has any of your immediate family had any of the following?
Tuberculosis Yes [ ] No [ ] Diabetes Yes [ ] No [ ]
Heart Disease Yes [ ] No [ ] Cancer Yes [ ] No [ ]
High Blood Pressure Yes [ ] No [ ] Emotional Disorders Yes [ ] No [ ]
Other (please specify)______________________________________________________________________________________________
PERSONAL HEALTH HISTORY
Other Medical Conditions: _______________________________________________________________________________
ALLERGIES TO: FOOD (List them)____________________________________________________________________________
DRUGS (List them)____________________________________________________________________________
MEDICINES ROUTINELY TAKEN:_________________________________________________________________________
HAVE YOU HAD OR SOUGHT MEDICAL ASSISTANCE FOR ANY OF THE FOLLOWING?
Asthma Yes [ ] No [ ] Pneumonia Yes [ ] No [ ]
Diabetes Yes [ ] No [ ] Prolonged Depression Yes [ ] No [ ]
Heart Disease Yes [ ] No [ ] Rheumatic fever Yes [ ] No [ ]
Hepatitis Yes [ ] No [ ] Ulcers Yes [ ] No [ ]
High blood pressure Yes [ ] No [ ] Urinary infections Yes [ ] No [ ]
Kidney Disease Yes [ ] No [ ] Venereal disease Yes [ ] No [ ]
Severe menstrual cramps Yes [ ] No [ ]
LIST ANY MAJOR ILLNESS___________________________________________________________________________
LIST ANY MAJOR SURGERY__________________________________________________________________________
PART B:
TO BE COMPLETED BY YOUR PERSONAL PHYSICIAN
PLEASE TICK: Normal; If Abnormal, please state Problem(s) in space provided:
Eyes [] Heart [] Skin [] Temperature []
Ears [] Vascular [] Lymph Nodes [] Pulse []
Nose [] Lungs [] Muscular/Skeletal [] Respiration []
Mouth [] Breast [] Nutrition [] B/P []
Throat [] Abdomen [] Neurological [] Height []
Thyroid [] Genitalia [] Spine [] Weight []
Chest [] Rectal [] Vision [] Urine []
Behavior [] Stool []
Abuse (Substance/Physical/Emotional)
Disabilities:
Other Medical Conditions: _____________________________________________________________________________
Problems: __________________________________________________________________________________________
___________________________________________________________________________________________________
BLOOD INVESTIGATIONS
FBC:__________________________________________ Hb:___________________________________________
Assessment_________________________________________________________________________________________
Mantoux-Date Given: ______/______/______ Results:_________________________________________
MM DD YY
Chest X-ray (If Mantoux pos.) ______________ Results:_________________________________________
REQUIRED IMMUNIZATION (Please update P.R.N.)
D.P.T. Primary series completed _____/_____/______ POLIO: Primary series completed ______/_____/______
MM DD YY MM DD YY
Last D.T. BOOSTER _____/_____/______ (Repeat If over 10 years duration) ______/_____/______
MM DD YY MM DD YY
MMR. VACCINE - 1st Dose _____/_____/______ 2nd Dose ______/_____/______
MM DD YY MM DD YY
MEASLES VACCINE _____/_____/______ RUBELLA VACCINE ______/_____/______
MM DD YY MM DD YY
NOTE: A: ALL STUDENTS 40 YEARS AND UNDER ARE REQUIRED TO HAVE: EITHER 2
DOSES OF MMR OR 1 DOSE OF MMR PLUS 1 DOSE OF MEASLES AND 1 DOSE
OF REBELLA VACCINE.
B: ALL STUDENT MUST PRESENT EVIDENCE OF A COMPLETED D.T. BOOSTER
WITHIN THE LAST TEN YEARS.
_____________________________ ___________________ ______/_____/______
1. PHYSCIAN’S NAME (Please Print) Physician’s Signature MM DD YY
2. ____________________________________________________________________________________________
BUSINESS ADDRESS OF PHYSICIAN:
3. _____________________________
TELEPHONE
(Medical Practitioner’s Stamp)
