Medical Certificate
Medical Certificate
Medical Certificate
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<strong>Medical</strong> <strong>Certificate</strong><br />
(This information will be used to make the College aware of any condition so that additional<br />
assistance can be given as appropriate. It will not be used for insurance purposes)<br />
Name: ......................................................................................................................<br />
Date of Birth: ......................................................................................................................<br />
Past significant medical history:<br />
...............................................................................................................................<br />
...............................................................................................................................<br />
...............................................................................................................................<br />
Current medical problems (e.g. asthma, epilepsy, diabetes):<br />
.............................................................................................................................................<br />
Allergies:<br />
...............................................................................................................................<br />
...............................................................................................................................<br />
Current medication:<br />
................................................................................................................................<br />
................................................................................................................................<br />
................................................................................................................................<br />
Please answer the questions below and elaborate if necessary<br />
Does this patient have any physical disability?<br />
................................................................................................................................<br />
................................................................................................................................<br />
................................................................................................................................<br />
Is there a history of depression or other mental condition?<br />
...............................................................................................................................<br />
...............................................................................................................................<br />
...............................................................................................................................<br />
...............................................................................................................................<br />
...............................................................................................................................
Is there a history of chronic infection (e.g. Hep B)<br />
.............................................................................................................................................<br />
.............................................................................................................................................<br />
.............................................................................................................................................<br />
Is there a history of alcohol/drug abuse?<br />
.............................................................................................................................................<br />
.............................................................................................................................................<br />
Does this patient have a learning disability?<br />
............................................................................................................................................<br />
Is this patient up to date with appropriate immunisations?<br />
............................................................................................................................................<br />
Are you aware of any reason why this patient would not be able to pursue further study?<br />
.............................................................................................................................................<br />
.............................................................................................................................................<br />
.............................................................................................................................................<br />
Physical Examination<br />
BP:<br />
............................................................................................................................................<br />
Urine:<br />
.............................................................................................................................................<br />
.............................................................................................................................................<br />
Doctor ......................................... ................................... ........................<br />
Name Signature Date<br />
Applicant ........................................ .................................... ...........................<br />
Name Signature Date
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