UNIVERSITY OF COLOMBO – SRI LANKA
STUDENT MEDICAL REPORT
HEALTH CENTRE
This report is compulsory and information should be accurate and complete. The information
is strictly confidential and is for the use of your further health care provision by the university,
and will not be revealed to anyone without your knowledge and consent. Please mail
(registered) this completed document directly to the following address and keep a copy with
you to be used in case of misplacement.
Chief medical officer,
Health Centre,
University of Colombo,
Colombo 03
Part – I
To be completed by the student
1. Name with initials: ..………………………………………………………………………………...................................
2. Registration Number: ………………………….…………………………………………………………………………
3. National ID Number: ………………………………… 4. A/L Index No: …….……………………………….
5. Date of Birth: ……………………………….. 6. Sex: …………………………………………
7. Nationality: ………………………………….. 8. Religion: …………………………………
9. Single / Married: …………………………..
10. Address: ………………………………………………………………………………………………………………………..
11. Attended school O/L: ……………………………………………………………………………………………
A/L: ……………………………………………………………………………………………
12. Extra Curricular Activities / Sport: ……………………………………………………………….…………………
13. Mother/Father living/dead: ……………………………………………………………………………………………
If dead what is the reason: …………………………………………………………………………………..
14. Mother’s occupation: ………………………. Father’s occupation ……………………………
15. No.of brothers and sisters and age: ……………………………………………………………………..
16. Food habits
Non vegetarian Vegetarian
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17. Have you been admitted to the hospital in the past? If so what is the condition? Have you
undergone major surgery / if so attach a photocopy of the diagnosis card.
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18. Are you taking treatment for chronic disease? If so what? (e.g. Diabetes mellitus, bronchial
Asthma, Mental illness, Epilepsy, Arthritis, heart diseases, eczema
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19. Are you having an allergy to food or drugs? Please specify.
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20. Person, to be contacted in an emergency?
Address: ......................................................................................................................................
Telephone Numbers: .................................................................................................................
I certify that the information furnished by me is correct.
Date: …………………………….. Signature of the student: ………………………
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Part – II
FOR USE OF MEDICAL OFFICER TO BE COMPLETED BY A SLMC
REGISTERED DOCTOR WITH M.B.B.S. QUALIFICATIONS.
Name of candidate: ………………………………………………………………………………………….......
Permanent Address: …………………………………………………………………………………………….
Faculty: …………………………………………… Course of Study: ……………………………………….
Registration Number……………………………………………………….
Signature of Applicant: ……………………………………………………
Weight Height
1.
(Without Shoes) (Without Shoes)
Condition of Teeth, Gums, Throat and Nasal Passages,
2. (a) Are the gums and teeth healthy?
(b) State of tongue, fauces and nasal passages
Examination of Heart
(a) Any Past History of Heart disease of Rheumatic Fever?
(b) Any cardiac enlargement?
3.
(c) Heart Sounds
(d) Murmurs
(e) Blood Pressure
Examination of Lungs
4. (a) Past History of Tuberculosis, Bronchitis or Asthma?
(b) Any abnormality clinically?
Examination of Abdomen
(a) Any evidence of enlargement of Liver or Spleen?
5. (b) Any past history of peptic ulcer?
(c) Are the kidneys palpable?
(d) Any other abnormalities?
Examination of the Nervous System,
(a) Any History of convulsions or Insanity?
6. (b) Any past History of Poliomyelitis?
(c) Fundi
(d) Reflexes,
Any defects of
(a) Vision ,
i. Without glasses R
7. L
ii. With glasses R
L
iii. Colour Vision
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(b) Hearing (i) Any hearing defects?
(ii) Any past history of discharge from ear
(c) Speech
Operations and other details,
(a) Has he/she ever had any operations or accidents?
(b) Any deformities – Congenital or acquired?
8.
(c) Any evidence of hernia, hydrocele , varicose veins or
Hemorrhoids
(d) Immunization
Chest X-ray, (if indicated by symptoms / signs only)
9.
Mantoux (if indicated)
Investigations
(a) E.C.G
(b) Blood
FBC
Hb%
Blood Group
10.
(c) Urine
Reaction
Specific Gravity
Albumin
Sugar
Deposits
Does the student need referral to a specialist regarding any
11.
medical condition? If so what is the condition?
I am of opinion that Rev./Mr./Mrs./Miss .……………………………………………………………………..
………………………………………………………….is fit/ not fit for studies in University of Colombo
for the following reasons:- …………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………
Date: ………………………………………… ………………………………………..
Signature of Medical Officer
Date: ………………………………………… …………………………………………
University Medical Officer
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