I. Confidential Medical Report Ii. Laboratory Report Iii. X-Ray Form
I. Confidential Medical Report Ii. Laboratory Report Iii. X-Ray Form
I. Confidential Medical Report Ii. Laboratory Report Iii. X-Ray Form
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,
D. If the answer to any of the questions is ‘Yes”, please give details below.
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.
Mr./Mrs./Ms:……………………………………………………………………….Aged………………
General appearance:………………………………………………………………………………………..
Skin:………………………………………………………………………………………………………..
Blood Pressure:…………………………………………………………………………………………….
Heart:……………………………………………………………………………………………................
Lungs:………………………………………………………………………………………………………
Abdomen:………………………………………………………………………………………………….
C.N.S:………………………………………………………………………………………………………
Locomotor System:………………………………………………………………………………………...
Laboratory Investigations
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
Programme………………………………………………………….Registration No:.……………………………
1)……………………………………………………………………….………………………………......................
2)………………………………………………………………………….……………………………......................
Signature…………………………………………….. Date:……………………………………
Name: …………….……………………………………………….………………….Sex:……..….Age:…..……...
1)……………………………………………………………………….………………………………...
2)………………………………………………………………………….……………………………...
Signature………………………………………….. Date:………………..…………………..
UNIVERSITY OF CAPE COAST
COLLEGE OF AGRICULTURE & NATURAL SCIENCES
SCHOOL OF PHYSICAL SCIENCES
DEPARTMENT OF OPTOMETRY
EYE SCREENING FORM
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
CLINICAL USE
MAG: NEAR
OD:
EXTERNALS
OS:
INTERNALS OD:
E/CD/D/… OS:
OTHER FINDINGS:
……………………………………………………………………………………………………………………………………………
…………………………………………………….
SIGN/STAMP
UNIVERSITY OF CAPE COAST
COLLEGE OF AGRICULTURE & NATURAL SCIENCES
SCHOOL OF PHYSICAL SCIENCES
DEPARTMENT OF OPTOMETRY
FRESH STUDENTS EYE EXAMINATION REPORT
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………………..
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