KSU7

KISII UNIVERSITY
Telephone: 0720875082 P.O. Box: P.0.BOX 408 40200 KISII-KENYA

Fax: Email: KISII UNIVERSITY

MEDICAL REPORT FORM
IMPORTANT:

1. Students are requested to complete part I of this form. Part II should be completed by the Medical
Officer examining the student. The complete Form should then be submitted to the Chief Medical
Officer/ Medical Officer in your respective campuses on the registration day.

2. Please Note that any medical services that the student may require outside the University’s medical
departments is direct responsibility of the parent / Guardian

PART I
a) Candidates Name NEWTON BASWETI MOGOI
First Last/Surname

Admission/Reg. ID No./KCSE
ED11/00841/23 40727101165/2022
No: Index No

Aug 22,2023 12:30

Signature: ........................ Date:
PM

Name of Parent / Guardian/ Next of Kin: ALICE BIYAKI MOGOI

Contact Address: KISII Phone : 0703463869

Signature: ..................... Date: Aug 22 2023

b) Have you ever been admitted to hospital?Yes/No NO

if so, state the reason for admission and date N/A

c)Have you had any of the following illnesses?

Tuberculosis or other chest infection NO

Fits , nervous disease or fainting attacks NO

Heart disease or rheumatic fever NO

Allergies to food or drugs NO

Diabetes mellitus NO

Mental illness NO

Asthma NO

If any of the above is yes, please give details and dates N/A

d) If there are any relevant details of your medical history not covered by the above questions,
N/A
please give particulars

Date Aug 22 2023 12:30 PM Signature ..............