St.Jude Hospital College of Nursing

Name of the Applicant:

Surname:

Weight:(In Kg)

Height:(In Cm)

Medical history of applicant

Childhood diseases:

Other diseases :

Operations:

Injuries:

Medical history of family, with special reference to chronic illnesses such as tuberculosis and mental or nervous disorders - Epilepsy :

Condition of:

Eyes :

Throat :

Ears:

Sinuses :

Nose:

Thyroid :

Skin:

Glands :

Headache

Seldom:

Sinuses :

Always :

Ears:

Sinuses :

Lungs:

Heart :

Rate and rhythm of pulse:

Blood Pressure :

Abdomen

Scars :

Tenderness:

Palpable Masses:

Urine

Albumin:

Sugar :

Stool :

Blood

Hb:

Group :

Rh :

ESR:

WBC :

DC :

Menstrual history

Regular:

Irregular :

How long :

Pain:

Is Bed rest required :

Posture:

Has the applicant any physical handicaps or blemishes:

A Large X-Ray film of chest with report, taken within 3 months of the actual admission is required. X-RAY HAS TO BE PRODUCED AT THE TIME OF ADMISSION. Report can be sent with this form.

Do you consider the applicant mentally and physically fit for nursing?…………… I have this day given Miss ……… …………………………a careful physical examination and found her in ……………………………… health.

MEDICAL - FITNESS CERTIFICATE

The Medical Examiner is requested to make a careful physical examination, otherwise defects found after her admission may lead to the rejection of the applicant.

Medical history of applicant

Condition of:

Headache

Abdomen

Urine

Blood

Menstrual history

A Large X-Ray film of chest with report, taken within 3 months of the actual admission is required. X-RAY HAS TO BE PRODUCED AT THE TIME OF ADMISSION. Report can be sent with this form.

Do you consider the applicant mentally and physically fit for nursing?…………… I have this day given Miss ……… …………………………a careful physical examination and found her in ……………………………… health.