UNIVERSITEIT VAN STELLENBOSCH - Matie

STELLENBOSCH UNIVERSITYFACULTY OF HEALTH SCIENCESMEDICAL REPORTALLIED HEALTH SCIENCES PROGRAMMESA. THE APPLICANT MUST COMPLETE THIS SECTION:1. SURNAME: ________________________________ STUD. NO.: _____________________2. FIRST NAME/S (ALL): _________________________________________________________3. DATE OF BIRTH: ________________________ 4. GENDER: ____________5. HOME ADDRESS: ____________________________________________________________6. HEALTH CONDITION DURING THE LAST FIVE YEARS:Any physical conditions (please specify) ____________________________________________________________________________________________________________________Chronic infectious conditions (please specify) ___________________________________________________________________________________________________________________Any physical impairments (please specify) _____________________________________________________________________________________________________________________Any psychological problems (anxiety, stress-related conditions, depression) (please specify)________________________________________________________________________________________________________________________________________________________7. FOR PHYSIOTHERAPY APPLICANTS ONLY:HAVE YOU HAD PAIN, TRAUMA, DISEASE OR ANY DEFECT OF THE SPINAL COLUMN?Supply details: _______________________________________________________________If so, a clinical examination by an orthopaedic surgeon has to be done and the report, withaccompanying x-rays, has to be supplied with this form._____________________________DATE_________________________SIGNATURE OF APPLICANTPage | 1

B. A MEDICAL DOCTOR MUST COMPLETE THIS SECTION. PLEASE GIVE FULLDETAILS OF THE INFORMATION REQUESTED AND DESCRIBE ANYABNORMALITIES.1. IS THERE A HISTORY OF CONGENITAL ABNORMALITIES, TRAUMA, OPERATIONS, ORILLNESSES? (BRIEFLY DESCRIBE)________________________________________________________________________________________________________________________________________________________2. MEASUREMENTS: HEIGHT: _________________ MASS: __________________3. SIGNS OF SUCCESSFUL VACCINATION PRESENT: _______________________________4. SIGNS OF TB-TEST PRESENT: _________________________________________________5. SIGNS OF HEPATITIS B VACCINATION PRESENT: _________________________________6. COMMENT ON THE FOLLOWING:• Vision:Visual acuity without glasses: right: _______________ left: _______________Visual acuity with glasses: right: _______________ left: _______________• Hearing: _______________________________________________________________• Speech: _______________________________________________________________• Respiratory system: ____________________________________________________• Cardiovascular system: __________________________________________________Blood pressure: _________________________________________________________• Nervous system: _______________________________________________________• Urine analysis: _________________________________________________________7. HAS THE APPLICANT BEEN ANXIOUS OR DEPRESSED WITHIN THE LAST FIVE YEARS:____________________________________________________________________________8. HAS THE APPLICANT EVER BEEN TREATED FOR A MENTAL CONDITION? (EG.ANXIETY, DEPRESSION, ANOREXIA, BULIMIA). IF YES, PLEASE DESCRIBE DURATION,TREATMENT AND CURRENT CONDITION:________________________________________________________________________________________________________________________________________________________9. IS THERE ANY CONGENITAL DEVIATION OR ANY PHYSICAL HANDICAP PRESENT?___________________________________________________________________________10. FOR PHYSIOTHERAPY APPLICANTS ONLY:SPINAL COLUMN: The nature of the course in Physiotherapy places certain demands on thevertebral column. During the course the student HAS TO:Page | 2

• Act as model for their peers to practice certain mobilization and manipulationtechniques on the vertebral column as well as peripheral joint.• Practice strenuous lifting etc. techniques• Handle patients of various size, mass and levels of consciousness.10.1 Is the standing posture and gait normal, specifically as far as spinal curves, pelvis and leglength is concerned?___________________________________________________________________________Is there scoliosis present? _____________________________________________________Is the range of movement normal for all the sections of the spine? ___________________10.2 In the case of a positive history, signs and symptoms of vertebral defects, please refer thiscandidate for orthopaedic assessment. State whether this candidate has been referred to anorthopaedic surgeon.________________________________________________________________________________________________________________________________________________________11. IN YOUR OPINION, IS THE APPLICANT FIT TO MEET THE PHYSICAL REQUIREMENTSOF THE COURSE?___________________________________________________________________________________________________________________________________________________________________________________DATE________________________________PLACE_____________________________SIGNATUREPage | 3