MEDICAL HISTORY & EMERGENCY CONTACTS – CLASS OF 2015-17 The information provided below will remain confidential and will be accessed and used only in the case of physical/mental health related issues/emergencies, or as deemed fit by the in-campus Medical/Counselling Centre. Please disclose all relevant information. Please Note: A consultation with the in-house doctor is mandatory, within the first 45 days from the date of registration. Admission No. Application No. A P U 1 5 P Programme G (Admission number to be filled on registration day) Name in Full (Block letters) ________________ First Name Gender Age Marital Status Blood Group Phone No.: Email ID: Emergency Contact person details (In case this person is not available, the University will reach out to other contacts mentioned in the Student information sheet) Address: Phone No.: Email ID: Address: Local Guardian at Bangalore (if any) _________________ Middle Name _______________ Last Name CURRENT HEALTH STATUS 1. Are you currently undergoing treatment for any health issues? Please specify  Physical/Mental Health Issues: …………………………………………………….………..………….…………………………….…………………………….…………………. …….……………………….…………………………….……………………….…………………………….……………………….…………………………….…………………………….………….………  Contact details of Physician/Psychiatrist/Therapist: …………………………………………………….………………………….…………………………… ……………………….…………………………….……………………….…………………………….…………………………….…………………………….…………………………….………….………  Name of medication (prescribed medicine), if any: ……………………………………………….……………………….……………………………….…… …………………………….………………………….…………………………….…………………………………………………….…………………………….…………………………….………….……… 2. Are you allergic to any medication? Please mention the details. ………………………………………….………………………….…………………………………………………….…………………………..….…………………………….………….……………………………. ………………………………………….………………………….…………………………………………………….…………………………..….…………………………….………….……………………………. PERSONAL MEDICAL HISTORY 3. Have you been treated in the past for any of the below?  Diabetes  Hypertension (BP)  Asthma  Cardiac diseases  Any other illness; please specify ……………………………………….…………………………………………………………………………………………... 4. Have you undergone any surgery in the past?  Yes  No If yes, please provide details ………………………………………………………….………………………………………………………………………………………. …………….…………………………….…..………………………….………….…………………….…………………………….…..………………………….………….…………………….…………………… 5. Have you ever suffered from any psychiatric illness?  Yes  No If yes, please provide details ………………………………………………………….………………………………………………………………………………………. …………….…………………………….…..………………………….………….…………………….…………………………….…..………………………….………….…………………….…………………… FAMILY MEDICAL HISTORY 6. Has any member of your immediate family been treated in the past for any of the below:  Diabetes  Hypertension (BP)  Cardiac diseases  Psychiatric illness  Any other illness; please specify ……………………………………………….…………………………………………………………………………………… Place: Date: Signature of student CERTIFICATE OF MEDICAL FITNESS (TO BE COMPLETED BY A MEDICAL DOCTOR) Name of student (Block letters) ……………………………………………………………………………………………………………………………………………… Vital signs: Height : ……………………………… Weight : ……………………………… Body Mass Index (BMI) : ……………………………..…… Blood Pressure : …………………….…………… Pulse rate : …………………………..…… Cardiovascular system: …………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Respiratory system: …………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Per Abdomen: …………………..………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Central Nervous System: ……………………………………………………………………………………………………………………………………………………………………………..… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………... ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ENT: ………………………………………………………………………………………………………………………………………………………………………………………………………………………….. Vision: ……………………………………………………………………………………………………………………………………………………………………………………………..……………………... Investigations (if any): ………………………………………………………………………………..…………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………….………………………………………………………………………………………………..… Findings and recommendation: …………………………………………………………….……………………………………………………………………………………………..…… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………… DECLARATION BY DOCTOR I hereby certify that I have examined ………………………………………………………..…………………………… (Name of student) ………………………………………………..……………………………………………………… and found him/her physically and psychologically fit to undergo his/her Postgraduate programme. Place: Name of Doctor Date: (Sign + Seal)