Medical Form

Name ____________________________ DOB__________ Blood Group_______

Student Mobile No. _________________
Batch____________________________ ID. No.___________________________
Father’s Name ___________________ Father’s Mobile No.__________________
Mother’s Name __________________ Mother’s Mobile No.________________

HISTORY
Yes No
Asthma
Heart Disease
Epilepsy
Bleeding Disorder
Diabetes
Any other

Details of medicines being taken, if any_________________________________

Any previous surgery ______________________________________________

ALLERGIES DETAILS
 Food
 Skin
 Drugs
 Respiratory

 Any other

Present Medication, if any__________________________________________

AU Med Form No. 1

pg. 1
Student Vaccine Information
Basic
Vaccine Name First dose Second Booster Vaccine
date Dose Date Dose Date Name
COVID
Tetanus Toxoid 
Hepatitis B   
1 2 3

Additional
Vaccine Name Regular Last Dose Date
HIB 
Typhoid 
Chicken Pox  
1 2
Any other

Student Personal Medical Insurance Policy No. and amount:

Contact number and name of Family Doctor in case of emergency :

_____________________________________________________________

Undertaking

I, the undersigned ___________________________ (name) hereby certify that

the information given above is true to my knowledge.

Date_________ Name___________________________

Signature________________________

CONFIDENTIALITY:

Ashoka University undertakes to keep the above information confidential.

AU Med Form No. 1

pg. 2