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PRE-MEDICAL INFORMATION
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PRE-MEDICAL INFORMATION
PRE-MEDICAL HISTORY INFORMATION / DECLARATION
Name on Certificate
*
Enrollment No
Date of Birth
*
   
Address
1.
Do you have any family history of :
Yes/No
a) Heart ailnment
Yes
No
b) Diabetes
Yes
No
c) Mental illness
Yes
No
d) Tuberculosis
Yes
No
2.
Whether you have undergone any surgical operatioin in the past?
Yes
No
3.
Do you take medicines regulrary?
Yes
No
4.
Do you have any body deformity or defect?
Yes
No
5.
Do you have any probklem of Rheumatism/Asthma/Joint pain?
Yes
No
6.
Do you have any large veins in your legs, thighs(varicose-veins)?
Yes
No
7.
Are you color blind?
Yes
No
8.
Do you have any hearing problem?
Yes
No
9.
Have you ever had any skin disorder?
Yes
No
10.
Have you ever had medical treatment for?
Yes
No
a) Allergies
Yes
No
b) Hay fever
Yes
No
c) Reaction to surgery
Yes
No
d) Reaction to medicine
Yes
No
e) Sprain
Yes
No
f) Fracture or broken bone
Yes
No
g) Diabetes
Yes
No
h) Fits
Yes
No
i) Eye trouble
Yes
No
j) Fainting spells
Yes
No
k) Heart trouble
Yes
No
l) Herina or Rupture
Yes
No
m) Injury to knee joints
Yes
No
n) Paralysis or weakness in arms or legs
Yes
No
o) Emotional upsets
Yes
No
p) Tuberculosis (TB)
Yes
No
q) Rheumatism
Yes
No
r) Prolonged fever
Yes
No
s) Back pain
Yes
No
t) Sacroiliac
Yes
No
u) Any other health condition
Yes
No
  Agree
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