New Student Medical Form Survey

All information gathered from this form is held confidentially by the Office of Student Affairs. If you have any questions about this for or wish to discuss its contents in more detail please contact the Dean of Students. Telephone: +44 208 332 8208 E-Mail: colesta@richmond.ac.uk

This form is a required part of the admissions procedure. It must be completed to the best of your knowledge. The University may require students to produce supplementary information regarding medical conditions upon request.

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* 1. Your full name: First, Middle & Last

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* 2. Date of Birth (Day/Month/Year):

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* 3. Nationality

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* 4. Religion

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* 5. Sex

Male

Female

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* 6. Name, address and telephone number of a person who can be contacted in an emergency

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* 7. Relationship of this person to you

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* 8. Please give us your emergency contact's personal email address.

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* 9. What is your height?

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* 10. What is your weight?

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* 11. How is your blood pressure?

High

Low

Average

If abnormal, please give more information.

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* 12. Have you been immunised for the following diseases within the last 5 years?

	Yes	No
Tetanus Toxoid	Tetanus Toxoid Yes	Tetanus Toxoid No
Poliomyelitis	Poliomyelitis Yes	Poliomyelitis No
BCG or Heaf	BCG or Heaf Yes	BCG or Heaf No
Rubella	Rubella Yes	Rubella No
Hepatitis B	Hepatitis B Yes	Hepatitis B No
Measles	Measles Yes	Measles No
Mumps	Mumps Yes	Mumps No

Other (please specify)

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* 13. Are you currently taking any prescription medication?

Yes

If yes, please specify and include frequency and dosage

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* 14. Have you ever had or been treated for any of the following?

Please give details to all 'yes' answers. You may be required to send further supporting documentation to the University.

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* 15. Given the demands of the University environment and the location in London, do you feel you'll require any specific support during your studies?

Yes

If you answered 'yes' please give more information.

	Yes	No
Heart disease, high blood pressure, varicose veins or disease of the circulatory system	Heart disease, high blood pressure, varicose veins or disease of the circulatory system Yes	Heart disease, high blood pressure, varicose veins or disease of the circulatory system No
Diabetes, goitre or any disease of the glands	Diabetes, goitre or any disease of the glands Yes	Diabetes, goitre or any disease of the glands No
Epilepsy, fainting attacks or other disease of the brain or nervous system	Epilepsy, fainting attacks or other disease of the brain or nervous system Yes	Epilepsy, fainting attacks or other disease of the brain or nervous system No
Fistula, fissure, haemorrhoids or other disease of the rectum	Fistula, fissure, haemorrhoids or other disease of the rectum Yes	Fistula, fissure, haemorrhoids or other disease of the rectum No
Cancer, tumour, syphilis or tuberculosis	Cancer, tumour, syphilis or tuberculosis Yes	Cancer, tumour, syphilis or tuberculosis No
Asthma, pleurisy, or other diseases of the respiratory tract	Asthma, pleurisy, or other diseases of the respiratory tract Yes	Asthma, pleurisy, or other diseases of the respiratory tract No
Migraine headaches	Migraine headaches Yes	Migraine headaches No
Glandular fever	Glandular fever Yes	Glandular fever No
Any viral illness	Any viral illness Yes	Any viral illness No
Hepatitis	Hepatitis Yes	Hepatitis No
Malaria	Malaria Yes	Malaria No
Neck or back strain or hernia	Neck or back strain or hernia Yes	Neck or back strain or hernia No
Any deformity or loss of limb	Any deformity or loss of limb Yes	Any deformity or loss of limb No
Any disease of the reproductive organs	Any disease of the reproductive organs Yes	Any disease of the reproductive organs No
Psychological or psychiatric difficulties requiring treatment and/or medication	Psychological or psychiatric difficulties requiring treatment and/or medication Yes	Psychological or psychiatric difficulties requiring treatment and/or medication No
Emotional difficulties including depression, phobias or anxiety	Emotional difficulties including depression, phobias or anxiety Yes	Emotional difficulties including depression, phobias or anxiety No
Anorexia, bulimia or any other eating disorder	Anorexia, bulimia or any other eating disorder Yes	Anorexia, bulimia or any other eating disorder No
Ulcer or any disease of the stomach, intestines, gall bladder or other disease of the gastrointestinal tract	Ulcer or any disease of the stomach, intestines, gall bladder or other disease of the gastrointestinal tract Yes	Ulcer or any disease of the stomach, intestines, gall bladder or other disease of the gastrointestinal tract No
Arthritis, rheumatism, or other disease of the bones	Arthritis, rheumatism, or other disease of the bones Yes	Arthritis, rheumatism, or other disease of the bones No
Any impairment of sight, speech or hearing or any disease of the eye, ear, nose or throat	Any impairment of sight, speech or hearing or any disease of the eye, ear, nose or throat Yes	Any impairment of sight, speech or hearing or any disease of the eye, ear, nose or throat No
Any surgical operation/procedure performed or been advised to have performed during the past 5 years	Any surgical operation/procedure performed or been advised to have performed during the past 5 years Yes	Any surgical operation/procedure performed or been advised to have performed during the past 5 years No
Any substance abuse	Any substance abuse Yes	Any substance abuse No
Allergic reactions to food, environment or drugs	Allergic reactions to food, environment or drugs Yes	Allergic reactions to food, environment or drugs No
Any special dietary needs, preferences or difficulties	Any special dietary needs, preferences or difficulties Yes	Any special dietary needs, preferences or difficulties No
Menstrual problems including irregular, painful periods an/or premenstrual syndrome	Menstrual problems including irregular, painful periods an/or premenstrual syndrome Yes	Menstrual problems including irregular, painful periods an/or premenstrual syndrome No
Any other illnesses, diseases, or treatments not mentioned above during the past 5 years	Any other illnesses, diseases, or treatments not mentioned above during the past 5 years Yes	Any other illnesses, diseases, or treatments not mentioned above during the past 5 years No