CONFIDENTIAL
MEDICAL FORM TO BE COMPLETED PRIOR TO THE EXECUTION OF SCHOLARSHIPS
OFFERED BY THE GOVERNMENT OF TRINIDAD AND TOBAGO
All candidates of government scholarships are required to submit a Medical Form. Medical
Forms must be presented to the Scholarships and Advanced Training Division prior to the
execution of the scholarship agreements.
GUIDELINES FOR COMPLETING THIS MEDICAL FORM
PART A PATIENT HEALTH QUESTIONNAIRE
All scholars are required to complete Sections 1 to 3 of this form.
PART B-MEDICAL CERTIFICATE OF EXAMINATION
This section is to be completed by a Registered Medical Practitioner and it includes a full
medical examination.
Please note that this form must be completed in its entirety by both the Scholar and
Medical Practitioner.
PART A PATIENT HEALTH QUESTIONNAIRE
SECTION 1: SCHOLAR INFORMATION (Complete using BLOCK letters)
Name: ___________________________________________________________________
Address:__________________________________________________________________
Date of Birth: ____/____/____
Gender: M
Age: ________
Contact Number: _____________________
Email:_______________________
Name of Parent/Next of kin: _______________________ Contact No: _______________
Name of Primary care physician: ____________________ Contact No: _______________
Have you been awarded a scholarship previously? Yes
No
If yes, please state __________________________________________________________
SECTION 2: GENERAL HEALTH
Do you have any pre-existing medical condition that may interfere with your ability to complete the
course of study? Yes
No
If yes, give details_________________________________________________________
Have you ever had any surgeries, serious acute illnesses, significant injuries or been hospitalized?
Yes
No
If yes, please give details ___________________________________________________
________________________________________________________________________
Do you have any physical disabilities?
Yes
No
If yes, please explain ____________________________________________________
Do you have any learning disabilities? Yes
No
If yes, please explain ____________________________________________________
Do you have any chronic medical condition? Yes
No
If yes, please explain ____________________________________________________
Are you currently taking any prescription medications/herbal preparations? Yes
No
If yes, please state the medication and the dosage________________________________
Have you ever had any allergic reaction to food, substances, past immunizations and/or
medication?
Yes
No
If yes, please state ________________________________________________________
Do you have a history of asthma or other respiratory ailment? Yes
No
If yes, give details _________________________________________________________
Have you ever received treatment for any psychiatric, mental health, eating disorder or
psychological condition? Yes
No
If yes, please state ________________________________________________________
SECTION 3: DECLARATION STATEMENT
I hereby verify that all of the information above is accurate and complete and acknowledge that any
failure to provide accurate and complete information on my part may result in the cancellation of the
scholarship.
Furthermore, I agree to notify the SATD of any material changes in my medical health that may occur
throughout the duration of my scholarship.
____________________________
Scholars Signature
_____/_____/______
Date
PART B: MEDICAL CERTIFICATE OF EXAMINATION/REPORT
To be completed by the Medical Officer
TO THE EXAMINING MEDICAL OFFICER: Please note that this individual is being considered
for the grant of a scholarship by the Government of the Republic of Trinidad and Tobago. As
such, we would appreciate your thoroughness in completing this form.
Please complete using BLOCK letters
Name of Patient: __________________________
Date of Birth: _____/_____/_________
Gender: M
Weight (kg): ____________________
Height(m)____________________
BMI: ________________________
PHYSICAL EXAMINATION- Please evaluate the following and note any abnormalities. Please
describe fully.
Normal()
1. Alimentary System
Appetite
Digestion
Bowels
Teeth
Tongue
Spleen
Liver
2. Respiratory
Nose
Chest expansion
Pharynx
Lungs
3. Circulatory System
Pulse
Blood Pressure
Heart
4. Nervous System
Temperament
Reflexes
Hearing
Sight
5. Reproductive System
Varicocele
Gonorrhea
Syphillis
Abnormal()
Comments/Remarks
Normal()
Abnormal()
Comments/Remarks
6. Urinary System
Specific Gravity
Albumin
Sugar
Deposit
Miscellaneous
i.
Is the patient medically fit to pursue his/her course of study? Yes
No
Please explain
_______________________________________________________________
_______________________________________________________________
ii.
Is the patient at present (a) undergoing a course of treatment
(b) receiving medical attention
(c) requiring medical attention.
If so, please give details
_______________________________________________________________
_______________________________________________________________
iii.
Do you recommend any additional treatment to be provided to the patient during his/her
course of study? Yes
No
If yes, please explain
_______________________________________________________________
______________________________________________________________
iv.
Do you recommend that the patient be referred for additional medical attention?
_______________________________________________________________
_______________________________________________________________
PHYSICIAN VERIFICATION
I certify to the best of my knowledge that the above mentioned information is true and
complete.
Name of Physician: _____________________________________________________
Address: ______________________________________________________________
Telephone No.__________________________________________
Signature: _____________________________________________
Medical Board Registration Number: _________________
Date: ________________
Physicians Stamp
