FORMJI/3

UNIVERSITY OF NAIROBI
STUDENT ENT CE ME ICAL EXAMINATION

REGISTRATIONNO: .. C~C32 .../i5GJ...i9P....................................... ..

IMPORTANT:
It is a University requirement that all the students joining the University must complete Part 1 of
this form. Thereafter he/she must complete Part II with assistance of a qualified and registered
medical doctor. Part III will be filled by the examining doctor who will thereafter print on the form
his full name and Medical Practitioners and Dentists Board Registration Number.
The completed form must be submitted to the office of Chief Medical Officer, University of
Nairobi, P:O. Box 30197-00100 Nairobi on or before the time of registration for further appropriate
action.
Any student seeking medical treatment at any of the University Medical Clinics must identify
himself/herself using Student Identity Card.
The Students are eligible for outpatient services at University Health Services only. Those requiring
hospitalization are admitted at Sickbay and if there is need for further specializ.ed care, they are
referred to Kenyatta National Hospital.
_ Please note that the_medical services are provided only when the students are in session. Pnvately
sourced medical services outside the University Health Services will not be honoured or paid for.
For full information regarding the students medical scheme, please check on the Students
Information Handbook.
PART 1:

SURNAME: .. /4.N.oovg··············· oTHERNAMEs: TAME.f .. M..v.(f!A¼A

GENDER: ... MA~ .......... ..
DATE OF BIRTH: .~ 0:.12.:.1.9 9~........ PLACE OF BIRTH ..\\................. ............. .. .
NATIONALITY::k~.N..Y.AN: ... MARITAL STATUs: ..f.l.N.Ed..i .. No. oF cmLDREN: .. ..
NAME oF P~NT/GUA RDIAN/NE xT ·oF KIN: .V.lN.C.k.NT .A.N..Dovf. ........... ..
POSTAL ADDRESS: ................. ................. ................. ..... . .... .................... .

TELEPHONE NO. (HOME): 0}0~.IJJ..68.3 ......... OFFICE: ............... . ·············· ······ ········
~ART II: (To be completed by the student with the doctor's help)
Have you ever been admitted into hospital? ... ... N.o...... ····· ............ .····························
If so, when and for what illness?................ ··························· ········· ··············· ............ .

Have )'.OU ever suffered from any of the following?

A.ii~~0, ...................... ·Y~;ii.j~. ··. ·······-j~;~;;~~~ M~~~~ucleosis Yes/No

Yes/No ·
Jaund'ice/H epatttis
·Anaemia
A thm Yes/No
s a Yes/No Peptic Ulcer Yes/No
B~ck P~oblem Yes/No Mental illness Yes/No
B1lharz1a Yes/No p 1.
Bladder problem Yes/No o iomye 1itis Yes/No
Ch Severe headaches Yes/No
est infections . Yes/No Su_rgery Yes/No

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 Yes/No
Diabetes mellitus Yes/No Thyroid disease
Yes/No
Epilepsy Yes/No Tuberculosis
Yes/No
Eye problem Yes/No · Speech problem .
Hearing problem Yes/No
Heart disease Yes/No Yes/No
High blood pressure Yes/No Se,<:ually transmitted djsease
Blood transfusion Irregularlmenstrual periods · Yes/No
Yes/No
Are you on any treattnent nc,w?Yes/No HIV infection Yes/No
AIDS Yes/No N()
If the answer to any of the above is YES, please give details ......................................... •· ••··•· ·.. ·· ··· ··· ·

·········································· .. ···········································································································
······················ ·························································································· ·························"·''''"''······
Family doctor ....... NO..................................................................... ...... ........._. ....................................
Any other medical cover, including NHIF cover for self, parents/guardians? ...... ~ 0. ........... :.....
................................................. ................................................ ..................................................................

FAMILY MEDICAL IDSTORY:

. Has any member of your family suffered from any of the following? NU
Diabetes mellitus · YesiNo Heart disease Yes/No
Bronchial asthma Yes/No High blood pressure Yes/No
Mental ill\less Yes/No Sickle cell di~ease Yes/No ·
Tuberculosis L,::,es/No
J,--::;;;;;-
DATE .. 1.s~.Au.6.. 202~ ........ .

1
I hereby authorize any doctor, hospital, clinic or medical providei, any inkurance company or any
company, institution any other Prrson: wµo lias any record or information about me and/or any of
my family members to provide University of Nairobi with complete information including copies of
their records with reference to my sickness or accident, any treatment, examination, advice or
hospitalization. Any photocopy of~s authorization shall be taken as the origin~ copy.

PART III: (To be completed by the Examining Doctor) ..... .... .. .. .... .. .. ..... ........ ............. .

Immunization record .... .f:,J»..i_ cg . . . ~. . /Ji. f .f. ~ .........................·.........

Height ./.f? .".'weight .... .'J 3./~······ ..... Any deformity .... . /:!JA.?. ...................... ·
Visual Acuity ..... V...... q~ 6 ..~ ·b·.................. RE.6 .. .. ~ .~. Y...............................

Hearing ..... .W,~ .......... Nose ..... /\!Vrh?............... Throat . /VI_.._ .'l1:!!. .......... .

Lymphatic glands ......... A~ ................................................................... .

CARDIOVASCULAR SYSTEM:

Pulse ......... :a.:J:. ....... J ;J~nute Regular/irr.egular .... & O.~·..............._. . .

.
Heart sounds .. .§ 4, ,?.;)... ...
d
IA_ ,1,1,r · · · · · r J. o-- -::i-
'/r.v.,: ............ .,. ... Blood pressure ... / ;,l,...>.. ...0 ............. : ..... .
.

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 • t • • t

Clinical findings ...... ·..... ~

1
.......... ...... ••• Resp1·ratory rate. • •••• .(;:l •••••••••• l
Percuss ion .......... ...... ~ UM.'~0Kl-/ ...
......... .... · · · · · · · · · · · ·, · Auscultat·Ion ······ .. ··········
U. o'YV'V
CXR., X-Ray and report should be submitted together with the form.

ALIM ENT~ 7 {M if~ . norm· .

........ ~
Teethffi.M./.......... .......... .Tongue ..... .MdJ.Y?. ..........Abdomen . ./01.?. .. -~

GENIT O-URIN ARY SYSTEM: . NY»t . ~ <

U~thral
. 1\/1 AJf)/1'
d~;r~. . ~~ . . ·:·· ; ·~-M.P......... . .......... ....Uterus ......... ....... .

Urme.~ r:J. ....... S.G... J.. P. .......Albumin ...... ~ .......... . Sugar.../Y1!!-::... .

..........

Deposit . ........ ~ r?. .............. ;...........................................................

'. ........ .
HIV test ... ,, ...... Ml() .~ :..............................................•••••••••·········: ·
COMM ENTS BY THE EXAMINING DOCTOR: r

........ :...... Ji/:t: .....t}~.. f··~ ·2/ ~ .... t:.{t.;.... /!0?. ......~ ··-.6 .( .?-:.1:. ........ .
ft/11 1//11 lJ r½r ,J/I/J/1/1/1
.......... .... J . .v..... r.~ ................. v..1..~.-:-~.......................... ·1·. tJ" r..F;f\~-i\: ......
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DOCTO R'SNAM E(Print ed) ·········~ ····;···· SIONA 1"~··,;l·····
· IONERS &
.
DENTIS
·
TS BOARD REG. NO
Is J. ~
........ ~. . DATE
J!J..r//J;»17
.. Jtf!t. {.-..
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MEDIC AL PRACT
\.. : - ~/-i-~ ~
. ~ :-1/ * p. 0 --~I.'
PART IV:

COMMENTS BY THE UNIVE RSiTY CHIEF MEDICAL OFFICER:

Special
.......... .
remarks .......... .......... .......... .......... .......... ........ .......... .......... .......... ..........
e • ~ t • • • • t • • t t • • t • t a • t • • • a ♦
• • • • a • • a • • • • • • f ■ • f • e • • • • ~ • f I • t ■ t I t • • • t • • t t f t t t • I t t f f ,o
• • • • • • • • • • • • • f • • • • f f • • •
• • • • • • • • • • • • • • • •

....... .
Does the student require any special medical needs? .......... .......... ........ ; .......... ..........
························································································································

.CHIEF MEDICAL OFFIC ER

UNIVERSITY HEALT H SERVICES DATE .. ·.......... .......... .... ~ .......... .. .

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