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OAU Health Centre - PDF R

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56 views1 page

OAU Health Centre - PDF R

Uploaded by

apostlecraig259
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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OBAFEMI AWOLOWO UNIVERSITY, ILE-IFE

STUDENT HEALTH SERVICE


HEATH CENTRE BIODATA FORM

PART I (To be completed by the student)

UTME NO: 202491025794HA

REGISTRATION NO: 202491025794HA

NAMES: FALOLA DANIEL ABIODUN DATE OF BIRTH: 28/12/2004

SEX: Male NATIONALITY: Nigeria Marital STATUS: Single ETHNIC ORIGIN: Yoruba

FACULTY:: Environmental Design And Management DEPARTMENT:: Estate Management

Next of Kin: Parent/Guardian

NAME: Falola David ---ADDRESS: 12, Soji Sanyaolu Street, Aparadija Ogunstate.

RELATIONSHIP: Brother TELEPHONE NUMBER: 08035141421

(B) Have you ever had or do you now have any of the following.
Arthritis No G.C Migraine No
Asthma No Genito-Urinary Disease No Parasitic / Worm Disease No
Bone, Joint Disease (Other Deformity) No Hay Fever No Poliomyelitis No
Bronchitis No Headache (Recurrent) Rheumatic Fever No
Diabetes No Heart Disease No Skin Disease (incl. leprosy) No
Eyes, Ears, Nose, Throat trouble No High Blood Pressure No Stomach or Duodenal Ulcer No
Dizziness or Fainting No Jaundice No Tuberculosis No
Drug Sensitivity No Kidney Disease No Schistosomiasis No
Dysentery No Liver or Gall Bladder Disease No Others (specify) Nil
Epilepsy/Fit No Malaria No Nil
Filariasis No Menstrual Disorders No

(C) Did you or do you smoke? No


Since When? Nill
What quantity per day? Nil
(D) What activity do you enjoy in your spare time? Nil
Do you take part in any athletic pursuits? Not At All
Do you represent your school in any sport? No If YES, which ? Nil

(E) Do you get very anxious at the time of class tests/exams? No

(F) Have you ever received counselling/treatment for emotional disturbances, nervous disorders or mental illness? No
(G) Give details of any serious illness, injuries and accidents, fracture or any operation you have had. Nil
(H) Give details of any previous admission into hospital as an in-patient for causes other than in (g) above. Nil
(I) State any current medical/surgical/psychiatric treatment you may be receiving. Nil
(J) Has any member of your family or a close relative suffered from tuberculosis, diabetes or mental nervousness? No
Please, give details. Nill

(K) Have you been immunised against?


DATE(S) DATE(S)
Poliomyelitis No 0001-01-01 Typhoid No 0001-01-01
Small Pox No 0001-01-01 Yellow Fever No 0001-01-01
Tetanus No 0001-01-01 Others Nil 0001-01-01
Tuberculosis No 0001-01-01

I certified that the above history is true to the best of my knowledge

Date ___________ STUDENT'S SIGNATURE ____________

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