International Students Office

Centre for International Cooperation Sq. Politechniki 1, 00-661 Warsaw, Poland

THIS PART IS TO BE FILLED BY CANDIDATE :

PERSONAL INFORMATION,
FULL NAME SEX DATE OF BIRTH [DD/MM/YY] NATIONALITY : :
:

FEMALE

MALE

/

/

:

CONTACT INFORMATION
STREET CITY POSTCODE COUNTRY : : : :

Medical Record is a systematic documentation of candidate’s medical history and care. It is used both for the physical folder for each individual case and for the body of information which comprises the total of each candidate’s health history. Medical records are intensely personal documents and therfore they are confidential and mentioned only for internal use of WUT. The information contained in the medical record allows to verify whether candidate can begin his studies and to provide appropriate conditions for each individual case.

Medical Record (besides the first page) is ment to be filled out by physician.

Copyright © Karol Maśluszczak 2009

International Students Office
Centre for International Cooperation Sq. Politechniki 1, 00-661 Warsaw, Poland

THIS PART IS TO BE FILLED ONLY BY A PHYSICIAN :

1. HEIGHT:

cm

WEIGHT:

kg

Blood Pressure: REFLEXES: Pupil Normal EYE-SIGHT: without glasses with glasses

Regular

Irregular

Abnormal Left Right

Knee Normal

Abnormal

Others Normal Abnormal Hearing: Left Right

Color-Blindness: Yes No

2. ANAMNESIS: Tuberculosis Cardiac Diseases Parasites

Please indicate with Y (Yes) or N (No) Malaria Diabetes Rheumatic Fever Allergy Epilepsy Kidney Disease

Abuse (alcohol/drugs/medicaments/etc.)

Any other serious diseases: (please specify)

3. PRESENT CONDITIONS: If disease is present, please indicate with Y (Yes) or N (No) Tonsil, Noise or Throat Stomach or Digestive System Other Abdominal Organs Blood or Endocrine System Heart or Blood Vessels Lungs of Respiratory System Genito-Urinary System Brain or Nervous System Bones, Joints Skin Venereal Disease* Parasites* HIV* / AIDS*

Abuse (alcohol/drugs/medicaments/etc.)

* Veneral Disease, Parasites or HIV results should based on current certificates.

Copyright © Karol Maśluszczak 2009

International Students Office
Centre for International Cooperation Sq. Politechniki 1, 00-661 Warsaw, Poland

4. If you put Y anywhere in point 2 or 3 Please use the back side of this form to describe in detail each disease, and if the applicant is physically handicapped, case of abnormality or impairment. 5. Describe the result of the current Chest X-ray examination and give its date. .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... 6. Has the applicant ever suffered from any nervous or mental disorder? .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... 7. In my opinion, the applicant’s health and physical condition is: Excellent Good Fair Poor

8. In my opinion, the applicant is physically sound and able to go abroad for study: Yes No

Copyright © Karol Maśluszczak 2009

International Students Office
Centre for International Cooperation Sq. Politechniki 1, 00-661 Warsaw, Poland

PHYSICIAN INFORMATION
FULL NAME PHYSICIAN TITLE : :

PHYSICIAN CONTACT INFORMATION
STREET CITY POSTCODE COUNTRY TELEPHONE EMAIL : : : : : :

Signature of Physician

Date

Copyright © Karol Maśluszczak 2009

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