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    WELINGKAR Medical - History - Form

    Uploaded by

    puttanmama

    Copyright:

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

    WELINGKAR Medical - History - Form

    Uploaded by

    puttanmama
    4 views4 pages

    Original Title

    WELINGKAR Medical_History_Form

    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
    4 views4 pages

    WELINGKAR Medical - History - Form

    Uploaded by

    puttanmama

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    S.P.

    Mandali’s
    Prin. L. N. Welingkar Institute of Management Development and Research (PGDM), Mumbai /
    Prin. L. N. Welingkar Institute of Management Development and Research, Bengaluru

    MEDICAL HISTORY FORM

    Passport Size
    Photo

    (A) To be filled by the Candidate

    (The information provided here will be strictly confidential and is to be used should any untoward incident occur)

    Full Name: ______________ ______________ ______________


    surname first name middle name

    Gender: Male / Female Blood Group: _________________________

    Course of Study: ________ __________ Campus: _____________________________

    Tel No: (Home) ___________________ (Mobile) ____________________________

    Local Guardian Name: _______________________________ Relationship: _________________

    Contact: (Home) _____________________________ (Mobile) ____________________________

    Family Physician Name and Contact No: _____________________________________________

    Contact: (Home) _____________________________ (Mobile) ____________________________

    2nd Vaccination Certificate No.: ____________________________________________________

    1. Do you wear glasses /contact lens? □No □Yes

    2. Do you wear any dental appliance (bridge/ crown/ plate)? □No □Yes
    3. History of smoking: □ No □ Yes # of cigarettes per day/week Since how long _____

    4. History of alcohol □No □ Yes How much _____ Since how long ___________

    Medical History Form Page 1 of 4


    5. Are you currently under medical treatment for any physical condition? □ No □ Yes

    6. Are you currently under treatment or have been treated in the last five years by a psychiatrist,
    clinical psychologist, or other mental health professional? □ No □ Yes

    If “Yes” to Question no 5 and/or 6, please provide details (diagnosis, treatment, date, duration, etc.)

    7. Are you currently taking ANY MEDICATION on a daily basis? □ No □ Yes


    If, YES, please list the medication and the conditions you are taking it for:

    Medication Condition

    No Condition □ No □ Yes Comment (medications if any)


    1 During or after exercise have you ever –

    - Passed out

    - felt dizzy or lightheaded

    - had chest pain

    - had shortness of breath

    8. Coronavirus (COVID‐19) Protection Plan

    Please declare if you have:


    • Have been infected with Covid -19 anytime? □ No □ Yes
    (If YES, pls indicate the time frame: From ____________________To _____________________)
    • Have been in direct or indirect contact with anyone who has been confirmed with the COVID‐19
    virus: □ No □ Yes
    • List all countries, states and hot spots that you have visited or traveled through in the last Six (6)
    month:
    (Specific Location/s:_____________________________________________________________)

    I understand that I am responsible for my own physical and mental health, and for informing staff of any need
    for treatment.

    I hereby affirm that all information supplied is complete and accurate to the best of my knowledge.

    Medical History Form Page 2 of 4


    I hereby grant permission to WeSchool to make necessary referrals; to release medical information necessary
    for appropriate care and treatment, and to authorize hospitalization when recommended in the event of illness
    or accident.

    I assure that I will inform and follow the medical / health protocols advised by the Institute and Medical centre
    in case I contact Covid-19. I also assure that I will abide by all the rules and regulations prescribed by the
    Institute.

    Parents, guardians, or local guardian will be promptly notified in the event of serious illness or accident, except
    when delay by such communication would endanger life. I understand that WeSchool cannot be held
    responsible for any medical incident occurring during my student days & for any financial obligations thereof.

    Name of the Student: _________________________________

    Signature of Student: _________________________________

    Date: _________________________________

    Contact No: _________________________________

    Name of parent or Guardian: _________________________________

    Date: _________________________________

    Signature of parent or guardian: _________________________________

    Contact No: _________________________________

    Medical History Form Page 3 of 4


    (B) To be Filled by the Physician

    1. History of Allergy: Please tick and explain their action

    None Medication Food Environmental

    2. Personal Medical History/Disorder/Problem – Please tick with brief comment where applicable

    No Condition □ No □ Yes Comment (medications if any)

    1 H/o any medical illness lasting for


    more than six months
    2 H/o any medical illness requiring
    overnight hospitalization
    3 H/o previous surgery

    4 H/o diabetes

    5 H/o High or Low BP

    6 H/o Jaundice
    7 H/o Kidney disease
    8 H/o Thyroid
    9 H/o Asthma
    10 H/o Convulsions (fits) / Seizures
    requiring medical supervision
    11 H/o Ear Nose Throat problems

    12 H/o Tuberculosis
    13 H/o Skin Rash / Eczema / Dermatitis /
    other Skin Disease / Allergy?
    14 Covid Symptom

    Name & Signature of Certifying doctor: _________________________________________________________

    Doctor’s Contact details: (Home) _________________________ (Mobile) ____________________________

    Place

    Date Doctor Seal & Medical Council Registration Number

    Medical History Form Page 4 of 4

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