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

Medical Student Health Assessment Page 8

Section 4: Doctor’s Certificate

Your patient has been offered a place to study medicine at XXXX.

All prospective medical students are required to complete a health questionnaire to help the

school plan to meet any requirements for disabled students, make reasonable adjustments to the

course to ensure that the applicant will be able to undertake the course successfully, and to

ensure that the student is fit, on health grounds, to work with patients and practise as a doctor

after qualification. We are not asking you for your opinion about their competence to practise, as

this will be assessed during the course. However, we do require applicants’ doctors to verify the

impairment/disability and health information provided by applicants on the basis of their

knowledge of the patient.

1. Are you the applicant’s usual doctor?

Yes

2. Are you a relative of the applicant?

Yes

3. Do you hold the applicant’ s medical record?

Yes

4. According to your records and knowledge of the applicant,

do the answers to questions in Section 2 appear correct?

Yes

Please add any comments below, if appropriate.

5. Are you aware of any additional medical information which

may be relevant to this application?

Ye s

If yes please provide details.

PLEASE NOTE. A medical examination is not required. Any fee required for completion

of the form is the responsibility of the patient.

Doctor’s Signature ________________________

Practice Stamp

Date ____________________________________

Medical Student Health Assessment Page 8