I. Confidential Medical Report Ii. Laboratory Report Iii. X-Ray Form

Download as pdf or txt
Download as pdf or txt
You are on page 1of 9

UNIVERSITY OF CAPE COAST

DIRECTORATE OF UNIVERSITY HEALTH SERVICES (DUHS)


PROCEDURES FOR STUDENT MEDICAL EXAMINATION

1. Download the following forms from the University website:


i. Confidential Medical Report
ii. Laboratory Report
iii. X-ray Form
iv. Fresh  Students’  Oral Screening Form
v. Eye  Screening  Form  &  Fresh  Students’  Eye  Examination  Report
2. Portions of the forms must be filled by Students appropriately.
3. Visit the Laboratory Unit of the University Hospital with the
Laboratory report form to collect specimen containers, and also for
your blood sample to be taken.
4. Report at the X-ray Unit with the X-ray form for the necessary
procedures to be done.
5. Report at the Dental Clinic with the oral form for the oral examination.
6. Report at the Eye Clinic with its forms for the eye screening.
7. Go back to the Laboratory and X-ray Units for the respective results,
and proceed to the OPD for procedures on weight, height, and blood
pressure.
8. The OPD In-Charge will schedule your consultation with a Medical
Officer for the medical examination and completion of the Confidential
Medical Report.
9. Submit a photocopy of the completed Confidential Medical Report as
well as your NHIS details (if available) and two (2) passport sized
photographs to HIRU (Records) Unit.
10. A hospital records card would be issued to you by HIRU (Records) if
they are satisfied with step 9.
11. The original copy of the Confidential Medical Report should be
submitted to the Directorate of Academic Affairs for further action.
12. Students are advised to keep photocopies of the Confidential Medical
Report for future references.
UNIVERSITY OF CAPE COAST
DIRECTORATE OF UNIVERSITY HEALTH SERVICES (DUHS)
CONFIDENTIAL MEDICAL REPORT
NAME:……………………………………………………  …………..REG.No:………………………………...

SECTION 1. To be filled by applicant with the help of a nurse or examining physicians, if necessary.

A. Have you ever suffered from or been advised that you have: (Underline Yes/No, where applicable)
1. Fits/Convulsion or Fainting Spells Yes No
2. Depression or any other mental illness Yes No
3. Anaemia Yes No
4. Sickle Cell Disease Yes No
5. Jaundice Yes No
6. Tuberculosis Yes No
7. Bronchitis Yes No
8. Pneumonia Yes No
9. Peptic Ulcer Yes No
10. Colitis Yes No
11. High Blood Pressure Yes No
12. Diabetic mellitus Yes No
13. Yaws Yes No
14. Leprosy Yes No
15. Gonorrhea Yes No
16. Syphilis Yes No
17. Drug or Alcohol problem Yes No
18. Asthma Yes No
19. Other Allergies Yes No
20. Chicken Pox Yes No
21. Typhoid Fever (Enteric fever) Yes No

B. Have you ever been admitted to a Hospital, Health Centre or Clinic? Yes/No,

C. In the case of a female applicant:


i. State the date of your Last Menstrual Period (LMP)
ii. Have you ever had any Obstetric or Gynaecological problem or operation? Yes/No

D. If  the  answer  to  any  of  the  questions  is  ‘Yes”,  please  give  details  below.

Disease or Injury Date Duration Name & Address of Doctor or Hospital

E. Family Record:
Has any member of your family ever had:-
Tuberculosis Yes No Myocardial Infarct (Heart Attack) Yes No
Asthma Yes No Cancer Yes No
Epilepsy Yes No Sickle Cell disease Yes No
Mental Disorder Yes No Obesity Yes No
Hypertension Yes No Allergic Condition(s) Yes No
Stroke Yes No G.6 PD – Deficiency Yes No

F. Declaration:

I  ……………………………………………………declare  that  the  forgoing  answers  are  true  and  that  no  
pertinent aspect of my medical history has been withheld.

Name  of  Witness:…………………………………           Signature  of  Applicant:……………………………………

Signature  of  Witness:…………………………… Date:………………………………………………..


SECTION II

Examining  Physician’s  Findings

This  is  to  certify  that  on………………………………………………………………………I  examined  applicant

Mr./Mrs./Ms:……………………………………………………………………….Aged………………

Of (Home Town/Address)…………………………………………………and  the  following  were  my  findings.

General  appearance:………………………………………………………………………………………..

Height  (in  cm):…………………………………………………..Weight  (in  kg)………………................

Skin:………………………………………………………………………………………………………..

Blood Pressure:…………………………………………………………………………………………….

Rate  and  Nature  of  Pulse:………………………………………………………………………………….

Heart:……………………………………………………………………………………………................

Lungs:………………………………………………………………………………………………………

Chest X-Ray,  dated:………………………………………………………………………………………..

Abdomen:………………………………………………………………………………………………….

C.N.S:………………………………………………………………………………………………………

Locomotor  System:………………………………………………………………………………………...

Ear/Nose  &  Throat:………………………………………………………………………………………...

Teeth  &  Gums:……………………………………………………………………………………………..

Eyes:  Left  Ext………………………………. Pupil/Accommodation……………V.A:……………………….

Right  Ext:……………………………                Pupil/Accommodation……………V.A:……………………….

Laboratory Investigations

1. Blood: Haemoglobin………..    Sickling……………         Hb-Genotype  (if  Indicated)…..............


Blood group/Rh (if indicated)…….......
2. Skin snip (if indicated)
3. Urine Albumen:
Sugar:…………………………..
SG:……………………………..
C/Deposit:……………………...
4. If female: Pregnancy test 9if indicated)
5. Sputum (if indicated)

Additional Remarks:………………………………………………………………………………………………
……………………………………………………………………………………………………..
……………………………………………………………………………………………………..
……………………………………………………………………………………………………..
In view of the above findings, I declare him/her FIT/UNFIT for admission/employment/to travel outside Ghana.

Signature:………………………………….

Official  Position:………………………….

Adress/Stamp:……………………………..

Date:………………………………………
UNIVERSITY OF CAPE COAST
DIRECTORATE OF UNIVERSITY HEALTH SERVICES-DUHS
FRESH  STUDENTS’  ORAL SCREENING FORM

Name: …………….……………………………………………….………………… Sex:……..….Age:…..……...

Programme………………………………………………………….Registration No:.……………………………

Part B – Dental  Surgeon’s  Findings


Teeth Present Decayed Teeth

Filled Teeth Missing Teeth

Other Conditions Present

1)……………………………………………………………………….………………………………......................
2)………………………………………………………………………….……………………………......................

Dental  Surgeon’s  Remarks


………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………..

Signature…………………………………………….. Date:……………………………………

UNIVERSITY OF CAPE COAST


DIRECTORATE OF UNIVERSITY HEALTH SERVICES-DUHS
FRESH  STUDENTS’  ORAL  SCREENING  FORM

Name: …………….……………………………………………….………………….Sex:……..….Age:…..……...

Programme………………………………………………………….Registration No:  .…………………………

Part B – Dental  Surgeon’s  Findings


Teeth Present Decayed Teeth

Filled Teeth Missing Teeth

Other Conditions Present

1)……………………………………………………………………….………………………………...
2)………………………………………………………………………….……………………………...

Dental  Surgeon’s  Remarks


………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………..

Signature………………………………………….. Date:………………..…………………..
UNIVERSITY OF CAPE COAST
COLLEGE OF AGRICULTURE & NATURAL SCIENCES
SCHOOL OF PHYSICAL SCIENCES
DEPARTMENT OF OPTOMETRY
EYE SCREENING FORM

Name:  ………………………………………………….……….. Index  No:  …..…..…………………………………………………….

Age:  ………….………………                    Sex:      M/F Phone  Number:  ……………………………………………………

Fathers  Occupation:  ……………………………………… Fathers  academic  qualification:  …………………………….

Mothers  Occupation:    …………………………………... Mothers  academic  qualification:  …………………………..

Please complete this questionnaire, After each symptom listed, circle the number that best describes how often you
experience that particular problem. 0=never, 1=(not very often) infrequently, 2=sometimes, 3=fairly often, 4=always
1 Do your eyes feel tired when reading or doing close work? 0 1 2 3 4
2 Do your eyes feel uncomfortable when reading or doing close work? 0 1 2 3 4
3 Do you have headaches when reading or doing close work? 0 1 2 3 4
4 Do you feel sleepy when reading or doing close work? 0 1 2 3 4
5 Do you lose concentration when reading or doing close work? 0 1 2 3 4
6 Do you have trouble remembering what you read? 0 1 2 3 4
7 Do you have double vision when reading or doing close work? 0 1 2 3 4
8 Do you see the words move, jump, swim or appear to float on the page when reading 0 1 2 3 4
or doing close work?
9 Do you feel like you read slowly? 0 1 2 3 4
10 Do your eyes ever hurt when reading or doing close work? 0 1 2 3 4
11 Do your eyes feel sore when reading or doing close work? 0 1 2 3 4
12 Do  you  feel  “pulling”  feeling  around  your  eyes  when  reading  or  doing  close  work? 0 1 2 3 4
13 Do you notice the words blurring or coming in and out of focus when reading or doing 0 1 2 3 4
close work?
14 Do you lose your place while reading or doing close work? 0 1 2 3 4
15 Do you have to reread the same line of words when reading? 0 1 2 3 4
Total Score 0 1 2 3 4

Please tick or fill space appropriate YES NO


1 Have you ever been prescribed glasses
If yes, were you able to obtain/purchase it?
If No, indicate the reason
If yes, Do you frequently wear it?
If No, indicate the reason
Who, where and when was it prescribed?
Do you know why the glasses were prescribed?
If yes, can you state it?
Does any member of your family wear glasses?
If yes, please list them
For what purpose do they wear the glasses
2 Have you heard about GLAUCOMA?
If yes, where did you hear about it?
In your own words, what is glaucoma?
Have you been tested for glaucoma?
If yes, what was the result of the test?
YES NO
3 Do you have a blind person in your family
If yes, do you know the cause of the blindness?
Can you name the cause of the blindness?
4 Do you always avoid sunlight?
5 Are you a frequent user of laptops or smart phones?
If yes, do you often feel burning sensation after prolonged use of the laptops or
smart phones?
Do tears come out from your eyes when using them?
Do  you  feel  like  there  is  an  object  on  your  eye  which  you  can’t  remove?
Do your eyes become red often?
6 Do you have any medical condition? E.g. asthma, Diabetes, Hypertension etc.
If yes, please specify
7 Does your eye itch often?
8 Do you know your sickle cell status?
If yes, are you positive?
If positive, what is your genotype? SS, AS etc.
What is the most disturbing eye problem you have?

CLINICAL USE

UNAIDED +100 WITH SPECTACLE RX CONTACT


PH VA AOA
SPH CYL AXIS @6M @0.4M LENSES
OD
OS
DATE OBTAINED

NPC COVER TEST OCULAR MOTILITY PUPILARY REFLEX CONFRONTATION


PHOPIA DIRECT OD OS
TROPIA OD OS CONSENSUAL

MAG: NEAR

OD:
EXTERNALS
OS:
INTERNALS OD:
E/CD/D/… OS:
OTHER FINDINGS:

DOCTORS REPORT REFERRED NOT REFERRED (TICK)

REASON FOR REFERRAL/DX: ………………………………………………………………………………………………………………………….........

INTERVENTION GIVEN: ………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………                                                                          

…………………………………………………….
SIGN/STAMP
UNIVERSITY OF CAPE COAST
COLLEGE OF AGRICULTURE & NATURAL SCIENCES
SCHOOL OF PHYSICAL SCIENCES
DEPARTMENT OF OPTOMETRY
FRESH STUDENTS EYE EXAMINATION REPORT

Name: ………………………………………………...…………………………………………………. Age: …..…..……………………………

Registration No:…………………………….………………………………………………………..Date:……………………………………..

FINDINGS
VISUALS ACUITY
Right Eye………………………………………………………………………… Left Eye……………………………………………………….
EXTERNAL EXAMS
Right Eye…………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………..
Left Eye.........................................................................................................................................................
INRENAL EXAMS
Right Eye…………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………..
Left Eye……………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………..…………………
REFRACTIVE  STATUS  …................................................................................................................................
………………………………………………………………………………………………………………………………………………………………..
ADDITIONAL  REMARK……………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………....
In view of the above findings, I declare him/her FIT/UNFIT for admission.

Signature: ………………………………………………………..
OPTOMETRIST
UNIVERSITY OF CAPE COAST
DIRECTORATE OF UNIVERSITY HEALTH SERVICES (DUHS)
X’RAY  FORM

NAME OF STUDENT:……………………………………………….SEX………..AGE………………..

REG No.: ……………………………HALL  OF  AFFILIATION: …………………….............................

PROGRAMME: …………………………………………………………………………………………...
MEDICAL EXAMS
BRIEF HISTORY: ……………………………………………………………………………...................
………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………..
CHEST
X’Ray  Required: ……………………………………………………………………………………………………..

………………………………………………………………………………………………………………………..

Date: ……………………………………
UHS
………………………………………………
Senior Medical Officer
PATH No.:
UNIVERSITY OF CAPE COAST
DIRECTORATE OF UNIVERSITY HEALTH SERVICES (DUHS)
LABORATORY REPORT
NAME OF STUDENT: ………………………………………………………………………………….SEX………………….AGE…………….......
REG No.: ………………………………………………………………HALL  OF  AFFILIATION: ……………………...............................................
PROGRAMME: …………………………………………………………………………………...................................................................................
MEDICAL EXAMS
SHORT HISTORY/IMPRESSION: ………………………………………………………………………………………………………………….....
……………………………………………………………………………………………………...................................................................................
UHS
REFERRAL  M.O……………………………………………………………………………..........................................................................................
Date Specimen Examination Result Signed Lab. No.
BLOOD HB
SICKLING
URINE RIE

You might also like