COUNCIL OF LEGAL

EDUCATION

NIGERIAN LAW
SCHOOL
MEDICAL CENTRE
STUDENT’S PERSONAL
DATA
SESSION: SPECIAL REMEDIAL
PROGRAM 2021

Surname:

Other Names:

Phone No:

Date of Birth:

Name of Next of Kin:

Address of Next of Kin:

Next of Kin Phone No:

Medical Data (to be filled by a Medical Doctor from a Government Hospital)

1. (a) Height metres (b) Weight kg
2. (a) Pulse (b) Blood pressure (c) Respiratory rate

3. (a) Heamoglobin estimation: _

(b) Genotype:
(c) Blood group:
(d) Clotting time: _

4. Urine analysis

5. Stool Analysis:

6. Chest
(a) X-ray (including report) :
(b) Sputum test for AFB:

7. Visual test
rl (with glasses ) _
rl (without glasses) _

8. (a) HepatitisvBsAg
(b) Hepatitis C Virus

9. Do you have allergy? If yes, state

10. Do you have the following? State yes or no

(a) Asthma (b) Heart Disease
(c) Hypertension (d) Epilepsy
(e) Migraine (f) Depression
(g) Tuberculosis (h) Diabetes
(i) Blood Disorder (j) Liver Disease
(k) Skin Diseases (l) Syncope
(m) Physical Defect (n) Others Specify
(o) Peptic Ulcer

State reason (if any)

11.
Have you ever been hospitalized? If yes state Reason(s)

12. Have you ever had blood transfusion? If yes state reason(s)

13. State any physical, medical or surgical problem (apart from those already listed) that may interfere with
your academic work during your stay in Law School:

14. State the last time you were immunised against the following diseases.
(a) Cerebrospinal meningitis Yellow Fever

15. Full name and address of government hospital with official stamp.

Signature of Medical Officer

Full name

Date

NB: Read Carefully

(1) The medical data portion of this form is to be completed, signed and stamped by a Medical Practitioner
from a government hospital.

(2) All completed forms duly signed and stamped, should be returned with the following:
(a) Chest X-ray with report A

(3) Accommodation shall only be given when the above have been complied with.