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BAHAMAS TECHNICAL & VOCATIONAL INSTITUTE
MEDICAL RECORD
Please return this form
dated, signed and stamped
from a Medical Doctor
in a sealed envelope marked
`MEDICAL RECORD’
To: THE ADMISSION OFFICE, BAHAMAS TECHNICAL &
VOCATIONAL INSTITUTE
PART A: GENERAL INFORMATION
TO BE COMPLETED BY APPLICANT, PARENT OR GUARDIAN
LAST NAME
FIRST NAME
MIDDLE NAME
ADDRESS (Street Name)
HOUSE#
P.O.BOX
TELEPHONE
(HOME)
(WORK)
DATE OF BIRTH: _____/_____/_____
AGE: _______
SEX: MALE [ ] FEMALE [ ]
MM DD YY
STUDENT NUMBER: ______________
SEMESTER: ____________
YEAR ENTERING BTVI______
MARITAL STATUS: MARRIED [ ]
SINGLE [ ]
__________________________________________________________________________________________________
PERSON TO NOTIFY IN CASE OF EMERGENCY
RELATIONSHIP
__________________________________________________________________________________________________
STREET ADDRESS
TELEPHONE (HOME)
(WORK)
FAMILY MEDICAL HISTORY
Has any of your immediate family had any of the following?
Tuberculosis
Yes [ ]
No [ ]
Diabetes
Yes [ ]
No [ ]
Heart Disease
Yes [ ]
No [ ]
Cancer
Yes [ ]
No [ ]
High Blood Pressure
Yes [ ]
No [ ]
Emotional Disorders
Yes [ ]
No [ ]
Other (please specify) _____________________________________________________________________________
PERSONAL HEALTH HISTORY
ALLERGIES TO: FOOD (List them) ____________________________________________________________
DRUGS (List them)____________________________________________________________
MEDICINES ROUTINELY TAKEN: _______________________________________________________
HAVE YOU HAD OR SOUGHT MEDICAL ASSISTANCE FOR ANY OF THE FOLLOWING?
Asthma
Yes [ ] No [ ]
Pneumonia
Yes [ ] No [ ]
Diabetes
Yes [ ]
No [ ]
Prolonged Depression
Yes [ ]
No [ ]
Heart Disease
Yes [ ]
No [ ]
Rheumatic fever
Yes [ ]
No [ ]
Hepatitis
Yes [ ]
No [ ]
Ulcers
Yes [ ]
No [ ]
High blood pressure
Yes [ ]
No [ ]
Urinary infections
Yes [ ]
No [ ]
Kidney Disease
Yes [ ]
No [ ]
Venereal disease
Yes [ ]
No [ ]
Severe menstrual cramps
Yes [ ]
No [ ]
LIST ANY MAJOR ILLNESS_____________________________________________________________
LIST ANY MAJOR SURGERY____________________________________________________________
PART B:
TO BE COMPLETED BY YOUR PERSONAL PHYSICIAN
PLEASE TICK: Normal or Abnormal, please state Problem(s) in space provided:
Eyes
[ ]
Heart
[
]
Skin
[
]
Temperature
[ ]
Ears
[
]
Vascular
[
]
Lymph Nodes
[
]
Pulse
[ ]
Nose
[
]
Lungs
[ ]
Muscular/Skeletal
[
]
Respiration
[
]
Mouth
[
]
Breast
[
]
Nutrition
[
]
B/P
[
]
Throat
[
]
Abdomen
[
]
Neurological
[
]
Height
[
]
Thyroid
[
]
Genitalia
[
]
Spine
[ ]
Weight
[
]
Chest
[
]
Rectal
[
]
Vision
[
]
Urine
[ ]
Behavior
[ ]
Stool [ ]
Handicap (Physical. /other)
Abuse (Substance/Physical./emotional)
Problems: _____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
BLOOD INVESTIGATIONS
FBC: __________________________________ Hb: ______________________________________
Assessment____________________________________________________________________________
Mantoux-Date Given: _____/_____/______ Results: ___________________________________
MM DD YY
Chest X-ray (If Mantoux pos.) ______________
Results: ___________________________________
REQUIRED IMMUNIZATION (Please update P.R.N.)
D.P.T. Primary series completed ____/____/____ POLIO: Primary series completed ____/____/____
MM DD YY MM DD YY
Last D.T. BOOSTER ____/____/____ (Repeat If over 10 years duration) ____/____/_____
MM DD YY MM DD YY
MMR. VACCINE-1st Dose ____/____/____ 2nd Dose ____/____/_____
MM DD YY MM DD YY
MEASLES VACCINE ____/____/____ RUBELLA VACCINE ____/____/_____
MM DD YY MM DD YY
NOTE: A: ALL STUDENTS 40 YEARS AND UNDER ARE REQUIRED TO HAVE: EITHER 2
DOSES OF MMR OR 1 DOSE OF MMR PLUS 1 DOSE OF MEASLES AND 1 DOSE
OF REBELLA VACCINE.
B: ALL STUDENT MUST PRESENT EVIDENCE OF A COMPLETED D.T. BOOSTER
WITHIN THE LAST TEN YEARS.
_____________________________ ___________________ _____/____/_____
1. PHYSCIAN’S NAME (Please Print) Physician’s Signature MM DD YY
2. ________________________________________________________________________________
BUSINESS ADDRESS OF PHYSICIAN:
3.
_____________________________
TELEPHONE