UNIVERSITY OF ILORIN

ACADEMIC OFFICE

UNILORIN HEALTH SERVICES REGISTRATION CERTIFICATE

This is to certify that the bearer, Mr/Mrs/Miss…………………………………………...

…………………………………………….of………………………………..Department

Level…………………….Faculty…………………………….Sex………………………

State of Origin……………………………………………Nationality…………………..

Matric No……………………...has completed his/her Registration with the University

Health Services.

Clinic Registration No. ………………………….. ……………………………………

Signature of Student …………………………..Date …………………………………..

Signature of the Director of Health Services ……………….. Date ……………………

 FORM MIS-01

STUDENTS INFORMATION FORM (SIF)

Affix
Affix
AA
1. REGISTRATION NUMBER -------------------------------------- LEVEL __________________ Affix
ARA A
Recent
Recent
Passport
Passport
2. NAME (Prof/Dr/Mr/Mrs/Miss) -------------------------------------------------------------------------------- Passport
Size
Size
Size
TITLE SURNAME FIRST-NAME MIDDLE NAME Photograph
Photograph
Photograph
with GUM ONLY
-------------------------------------------------------------------------------
FORMER SURNAME IF ANY

3. SEX 4. DATE OF BIRTH DAY MONTH YEAR 5. NATIONALITY CODE

M/F

6. PLACE OF BIRTH_________________________________________________________________________________________________________
TOWN/VILLAGE STATE
7. PLACE OF ORIGIN _________________________________________________________________________________________
TOWN/VILLAGE STATE L.G.A. CODE

8. MARITAL STATUS (S – SINGLE D- DIVORCED)

(ENTER APPROPRIATE LETTER) (M – MARRIED W-WIDOW)

9. RELIGION (C - CHRISTIANITY T – TRADITIONAL)

(ENTER APPROPRIATE LETTERS) (ISLAM O – OTHERS)

10. ADDRESS

(A) PERMANENT/HOME ADDRESS _______________________________________________

_______________________________________________
(B) CONTACT ADDRESS _______________________________________________

_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
11. NEXT OF KIN NAME _______________________________________________
ADDRESS _______________________________________________
_______________________________________________
RELATIONSHIP _______________________________________________
TELEPHONE _______________________________________________
12. SPONSOR NAME _______________________________________________
ADDRESS _______________________________________________
_______________________________________________
_______________________________________________

13A. MODE OF ENTRY (TICK ONE) (C-CONCESSIONA, R – REMEIDAL).

FOR UNDERGRADS ONLY) (J-JME D –DIRECT, T –TRANSFER, M – MATURE)
ENTER APPROPRIATE LETTER

13B, IF TRANSFER, PREVIOUS UNIVERSITY _________________________________________________________________

13C. PROGRAMME TYPE S-SUB DEGREE, F – FIRST DEGREEM, P – POST DIP/CRT, H – MASTER/Ph.D.

14. HIGHEST QUALIFICTION 1. SSCE 2.WASC/GCE OL. 3 TCH/AGE 4. HSC/GCE AL, 5. ND.
(ENTER APPROPRIATE NUMBER) 6. HND. 7. NCE 8. BACHELOR’S DEGREE 9. PGD 10. MASTERS
11. Ph.D 12. OTHERS PLEASE SPECIFY _________________________

15. QUALIFICATION WITH DATES:

A. SSCE/GCE/OL (With Grades) (B) GCE/AL/IJMB ( With Grades)

……………………………………………………….. ……………………………………………………..

………………………………………………………….. ……………………………………………………..

……………………………………………………………. …………………………………………………..

15B. INSTITUTION WHERE OBTAINED: ________________________________ DATE_________________

 16. SUBJECT OF FIRST DEGREE ____________________________________________________
(FOR POSTGRADUATE ONLY)

17. YEAR OF ENTRY INTO PRESENT INSTITUTION _____________________________________________

18. AWARD IN VIEW _______________________________________________________________________

CODE
19. COLLEGE _______________________________________________________________________________

20. FACULTY/SCHOOL_____________________________________________________________________________
CODE
21. DEPARTMENT/INSTITUTE ______________________________________________

22. MODE OF STUDY

(ENTER APPROPRIATE LETTER)

(F- FULL TIME P-PART TIME (DAY)

(W- WEEKEND E-EVENING)
(S- SANDWICH/LONG VACATION
(O-OCCASIONAL X-EXCHANGE)
(C-CORRESPONDENCE)

23. NORMAL COURSE DURATION __________________________________________________________

24. EXTRACURRICULAR ACTIVITIES ______________________________________________________________

_______________________________________________________________

25. HEALTH STATUS

NORMAL DISABLED

26. IF DISABLED, STATE ____________________________________________________________________

IF SPECIAL MEDICATION IS REQUIRED STATE TYPE _______________________________________

_______________________________ ___________________________
SIGNATURE OF STUDENT DATE
 UNIVERSITY OF ILORIN
STUDENT ENTRANCE MEDICAL EXAMINATIONS

Undergraduate And Postgraduate students are requested to complete

Part of this form, Part II should be completed with the help of the
Passport
University Medical Doctor. The form should be returned to the Director, Size
University Health Services after completion. The information will be treated Photograph
in strict confidence.

PART 1 (to be filled in by the student)

Surname: ……………………………….. Other Names: ………………………………………………………………

Age next Birthday:……………………………… Sex:…………….. Married or Single………………………………
Nationality: ……………………………………. State of Origin………………………………………………………
L.G. A.:……………………………………………………………..

Faculty:………………………………………………………………………………………………………………….

(a) Would you say your health was good/fair/poor:………………………………………………………………………..

(b) Have you ever been admitted as an in-patient into a hospital ?………………………………………………………….
If so please state reason for admission, name of Hospital and date

…………………………………………………………………………………………………………………………..

(c) Do you suffer from or have you suffered from any of the following:
Tuberculosis : YES/NO

Passing blood in the urine …/ Yes/No Any disease of the heart Yes/No

Any respiratory disease/ Yes/No Any general disease of the Kidneys/bladder Yes/No

Any disease of ear, nose and throat /Yes/No

Allergies e.g. asthma Yes/No Any disease of the digestive

e.g Peptic ulcer, hernia,
piles etc. Yes/No

If the answer to any of the above is yes, please give details with dates:
…………………………………………………………………………………………………………………………...
…………………………………………………………………………………………………………………………..……………………
……………………………………………………………………………………………………...
…………………………………………………………………………………………………………………………...

(d) If there are any other relevant details of your Medical history not covered by the above questions, please
give particulars:………………………………………………………………………………………………………….

(e) Is your family a healthy one?…………………………………Has any of your family suffered from
Tuberculosis, insanity or mental disease? ………………………………………………………………………………

(f) Have you been immunized against any of the following:

Small Pox Yes/No:……………………………………………………………………………………..

Tetanus Yes/No: …………………………………………………………………………………….
Others Yes/No:……………………………………………………………………………………..
Date………………………Student: …………………………………………………………………………………….
Signature
PART II ( To be completed by the University Medical Doctor)
Visual acuity:
Without Glasses R 6/ L. 66/ x Snellon Types
With Glasses R 6/

Hearing Circulatory System

Left Heart
Right Blood Pressure

Respiratory System
Eyes Lungs
Ears Abdomen
Pharynx Liver
Teeth Spleen
Lymphatic Glands Hernia
Skin
C.N.S. Urine
Pupillary Reflexes Alb
Spinal Reflexes Sugar
Chest X.Ray

Film No…………………Hospital………………………….Attach Radiologist Report

ANY OTHER OBSERVATIONS:

Remarks…………………………………………………………………………………………………..
Date……………………………………………………………………………………………………….
Medical Officer
Address……………………………………………………………
………………………………………………………….
………………………………………………………..
 UNIVERSITY OF ILORIN
STUDENT AFFAIRS UNIT

STUDENT PERSONAL DATA Passport No:……………………………

p Date Issued:…………………………….
Passport size
Photograph
p Where Issued: ………………………….

Passport Valid till:………………………

Visa/Residence Permit Valid till: ………

(PLEASE COMPLETE LEGIBLY IN BLOCK LETTERS

AND RETURN TO STUDENT AFFAIRS DIVISION)

1. Surname:………………………………………………………………………………………………………...........
2. Other Names:………………………………………………………………………………………………………….
3. Date of Birth ………………………………………………………………………………………………………….
4. Place of Birth: (Home Town): ………………………………………………………………………………………..
5. State of Origin: ……………………………………………………………………………………………………….
6. Nationality:…………………………………………………………………………………………………………….
7. Permanent Home Address:…………………………………………………………………………………………….
8. Vacation Address:……………………………………………………………………………………………………..
9. Name and Address of Guardian in Ilorin: ……………………………………………………………………………..
10. Sponsor (Full Name and Address): …………………………………………………………………………………….
………………………………………………………………..Telephone……………………………………………...
11. University (ties) previously Attended: ………………………………………………………………………………….
12. Year and Reasons for Leaving: …………………………………………………………………………………………..
13. Any Special and Continuous Medical Treatment Being Received and where:……………………………………………..
…………………………………………………………………………………………………………………………...
14. Marital Status:………………………………………No. of Children…...……………………………………………...
15. Precious NYSC Service: Yes/No
16. Service Year:…………………………………………..Discharge Certificate No.:…………………………………….
17. Hall of Residence and Room No.: ……………………………………………………………………………………...
18. When Expected to go Off Campus:……………………………………………………………………………………..
19. Off Campus Address:……………………………………………………………………………………………………
…………………………………………………………………………………………………………………………..
Faculty:………………………………………………………………………………………………………………….
Department:……………………………………………………………………………………………………………..
Present Year of Study: ……………………………………………………………………………………………..
Full Time Part -Time Occasional
20. Subject Combination:……………………………………………………………………………………………………
21. Year of Entry and Matriculation No:…………………………………………………………………………………....
22. Year of Graduation:……………………………………………………………………………………………………..
___________________________________________________________________________________________________
INFORMATION ON PARENTS
1. Father’s Full Name and Contact Address:………………………………………………………….
……………………………………………………………………………………………………
2. Mother’s Full Name and Contact Address:………………………………………………………..
…………………………………………………………………………………………………………………………...