MEDICAL FORM TO BE COMPLETED PRIOR TO THE EXECUTION OF SCHOLARSHIPS OFFERED BY THE GOVERNMENT OF TRINIDAD AND TOBAGO

CONFIDENTIAL

All candidates of government scholarships are required to submit a Medical Form. Medical
Forms must be presented to the Scholarships and Advanced Training Division prior to the
execution of the scholarship agreements.

GUIDELINES FOR COMPLETING THIS MEDICAL FORM

PART A – PATIENT HEALTH QUESTIONNAIRE

All scholars are required to complete Sections 1 to 3 of this form.

PART B-MEDICAL CERTIFICATE OF EXAMINATION

This section is to be completed by a Registered Medical Practitioner and it includes a full
medical examination.

Please note that this form must be completed in its entirety by both the Scholar and
Medical Practitioner.

PART A – PATIENT HEALTH QUESTIONNAIRE

SECTION 1: SCHOLAR INFORMATION

(Please enter your First , Middle, and Last Name)

Date of Birth

MaleFemale

Have you been awarded a scholarship previously?

SECTION 2: GENERAL HEALTH

Do you have any pre-existing medical condition that may interfere with your ability to complete the
course of study?

Have you ever had any surgeries, serious acute illnesses, significant injuries or been hospitalized?

Do you have any physical disabilities?

Do you have any learning disabilities?

Do you have any chronic medical condition?

Are you currently taking any prescription medications/herbal preparations?

Have you ever had any allergic reaction to food, substances, past immunizations and/or
medication?

Do you have a history of asthma or other respiratory ailment?

Have you ever received treatment for any psychiatric, mental health, eating disorder or
psychological condition?

SECTION 3: DECLARATION STATEMENT

I hereby verify that all of the information above is accurate and complete and acknowledge that any failure to provide accurate and complete information on my part may result in the cancellation of the scholarship. Furthermore, I agree to notify the SATD of any material changes in my medical health that may occur throughout the duration of my scholarship.

Full Name(Please enter your First , Middle, and Last Name)

Date