Is the examinee suffering from any of the following? Indicate Yes or 13. Kidney or urinary disease. 14. Diabetes.15. Epilepsy.16. Deformity.17. Psychotic. …

ST AUGUSTINE UNIVERSITY OF TANZANIA
PO BOX 307,
MWANZA, TANZANIA

MEDICAL CERTIFICATE

SURNAMEOTHER
NAMES
AGE SEX
MARITAL
STATUSCITIZENSHIP

PERSONAL HISTORY

Is the examinee suffering from any of the following? Indicate Yes or No

1 Tuberculosis 2
Pneumonia
3 Pleurisy 4
Asthenia
5 Rheumatic Fever 6 Allergy
disorder
7 Heart Disease 8 Gastric or
duodenal
9 Recurrent indigestion 10
Jaundice
11 Dysentery 12 Varicose
Veins
13 Kidney or urinary disease 14
Diabetes
15 Epilepsy 16
Deformity
17 Psychotic 18 Eye
disorder
19 Ear , Nose or Throat disorder 20 Skin
disease
21 Anemia 22 Gynecological
disorder
23 Malaria other tropical disease 24
Cholera
25 Major or minor operations 26 Serious
accidents
27 Any other serious disorder

PHYSICAL EXAMINATION

1 Height 2
Weight
3 Skin disease 4 Eye Conjunctivae

Pupils
Vision Right

Left
5 Please state condition of Ears if any
discharge
Mouth and throat
Nose
6 Any Abnormality
7 Cardiovascular System
Blood Pressure:
SystolicDiastolic
Heart: Any Murmur?
Arteries and Veins

8
AbdomenHernia

Hydrocele
Masses
Liver
Kidneys
Rectal
Any Clinical evidence of hyperacidity or gastric duodenal
ulcer?

LABORATORY

1 Urine Albinum
Sugar
Bilharzia
2 Stool: Special emphasis on Hookworm or Bilharzia
3 Blood examination : Hb Level
a Neuotrophils
b Eusinophils
c Bisophils
d Lymphocytes
e Monooytes
f ESR
4 X-ray examination
-Chest

5 Scrology: widal
TestVDRL

6 Pregnancy Test

CONCLUSION

I have examined
Mr/Mrs/Miss/Sr/Br/Fr
and considered that he/she is/is not physically and mentally fit
to be admitted to higher studies

Date Signature Name

Title Qualifications

Address :

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