Medical Student Health Assessment (Page 6 of 8) in pdf

Medical Student Health Assessment Page 6

4. Have you ever been affected by:

Sudden loss of consciousness? e.g. a fit or seizure

Ye s

Chronic fatigue syndrome? (or similar condition)

Ye s

An illness requiring more than 2 weeks absence

from school/work?

Ye s

Mental health problems? e.g. anxiety, depression, phobias,

obsessive-compulsive disorder (OCD), nervous breakdown,

personality disorder, over-dose/self-harm, drug/alcohol dependency

Ye s

An eating disorder? e.g. bulimia, anorexia nervosa, compulsive

eating

Ye s

If yes to any of the above, give details e.g. when condition developed, effects, treatment

and course adjustments required.

5. Have you ever been assessed or treated by a psychiatrist, psychotherapist or counsellor?

Yes

If yes give details e.g. when, reason, outcome.

6. Are you currently taking any medication or treatment?

Yes

7. Do you have any impairment or health condition not already mentioned for which you think you

may require support or adjustments during your education or training?

Yes

If yes to either of the above, give details.

What is your height? ______ metres. What is your weight? ______ kg.

Medical Student Health Assessment Page 6