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    Health Declaration Innobminds

    Uploaded by

    coolhoneyikk

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Health Declaration Innobminds

    Uploaded by

    coolhoneyikk
    6 views3 pages

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    6 views3 pages

    Health Declaration Innobminds

    Uploaded by

    coolhoneyikk

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    Health Declaration Form

    UCOL is a polytechnic under the Education Act.


    A declaration of an applicant’s past and present health status is a requirement for entry into this
    programme. While health problems are not a barrier to entering a programme, it is important that the
    Programme Leader is aware of them and can discuss them fully with you. Please answer all questions
    in this section, then make an appointment with your Doctor who should complete the medical
    report section.
    THE INFORMATION GIVEN WILL BE HELD IN THE STRICTEST CONFIDENCE.

    Section A - to be completed by applicant


    Family Name First Name(s)

    Address

    Telephone Number May we approach your Doctor if necessary to do so?


    No Yes

    If Yes, please give your Doctor’s name and address

    Programme applied for

    Have you ever suffered form any of the following?


    No Yes
    1 Back problems
    2 Joint problems
    3 Foot or leg problems
    4 High blood pressure
    5 Rheumatic Fever
    6 Heart complaint
    7 Allergies of any kind
    8 Varicose veins
    9 Slight defects
    10 Head injury
    11 Severe or recurrent headaches
    12 Epilepsy, fainting attacks, fits or blackouts
    13 Diabetes or kidney complaints
    14 Asthma, bronchitis, pleurisy or lung disease
    15 A substance related disorder, dependence or abuse
    16 Mental illness requiring psychiatric care
    17 Are you on medication?
    18 Other, please specify ___________________________________

    Signature of applicant Date


    Day Month Year
    Section B - to be completed by Doctor
    Name of applicant

    Are you this person’s regular Doctor?


    No Yes
    Please list any current or chronic condition(s) which require(s) regular or periodical medical attention and describe any condition/
    disability of any nature which may affect successful completion of the programme. (Any previous problems which may recur
    should also be noted here.)

    Please state medications of any kind which the applicant is currently taking or has taken in the previous three months (excluding
    oral contraceptive.)

    Name

    Address

    Signature Date
    Day Month Year

    Please complete next (attached) page regarding applicant’s immune status.


    Section c - to be completed by Doctor
    Name of applicant

    What is the applicant’s immune status? (If unsure, serology must be checked.)

    If no, please Result of serology


    Vaccination / If yes, please
    Yes (please tick) No (please tick) advise date of Immune /
    Immunisation advise date
    serology results not immune

    Tuberculosis (TB)
    N/A N/A
    (BCG)

    Hepatitis A

    Hepatitis B

    Hepatitis C (Not
    applicable for
    nursing students)

    Measles

    Mumps

    Rubella

    Chicken Pox

    Tetanus N/A N/A

    This completed Health Declaration MUST be returned by the doctor to:


    Student Registry
    UCOL
    Private Bag 11022
    Palmerston North

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