GESONDHEIDSINFORMASIE / HEALTH INFORMATION

Slegs studente / Students only

Jaar van eerste registrasie: Year of first registration:

Y Y Y Y

Student nr./ Staff nr.: Datum / Date: D D M M Y Y

Van / Surname:

Volle name / Full names:

Noemnaam / First name:

Potchefstroomadres / address:

Dui koshuis aan/ Indicate hostel

Huisadres / Home address:

Kontaknommers / Contact numbers:

Tel: Sel / Cell:

E-pos/ Email:

I.D. nommer / I.D. number: Manlik/ Male Vroulik/ FemaleHuistaal / Home language: Afrikaans English Tswana Ander (noem)/ Other (specify):

Kursus / Course: Voltyds/ Full time

Deeltyds/ Part time

Beroep/Occupation: Permanent Kontrak/ Contract

Ouers of naasbestaande / Parents or next of kin:

Naam/ Name: Verwantskap/ Relationship:

Adres/ Address:

Tel no./ nr. Sel/ Cell:

Huisdokter/ Family doctor: Tel no./ nr.

Potch Dokter/ Potch doctor: Tel no./ nr.

Mediesefonds/Medical aid: Naam/ Name: No./Nr:

Hooflid/ Main member:

Opsie/Option:

ID no./ID nr.: Tel. Werk/Work:

Finansiële steun/ Financial support:

Nee / No

Ja/Yes

Beurs / Bursary

Bank Lening / Loan

Lening (ander)/ Loan (Other)

NSFAS Ander/ Other:

Bestaande mediese toestande/ Existing medical conditions:

Hoë Bloeddruk/ Hypertension Epilepsie/ Epilepsy

Diabetis Mellitus Hartkwale/ Cardiovascular disease

Asma/ Asthma Fisies Gestremd/ Physical disability

Depressie/ Depression Angs/ Anxiety

Ander/Other Ander/Other

Kroniese medikasie/ Chronic medication:

Allergieë/ Allergies:

Operasies/ Operations:

Immuniserings laaste 10 jaar/ Immunisations last 10 years:

Masels Measles

Meningitis Meningitis

Pampoentjies Mumps

Duitse Masels Rubella

Ander Other

Gesondheidverwante situasies word op kampus deur die volgende rolspelers behartig: / Health related situations are dealt with on campus by the following role-players:

Emosionele en sielkundige krisisse Emotional and psychological crises

Primêre Gesondheidsorgdienste Primary Health Care Services

Noodmediese-dienste Emergency Medical Services

File No. / 2018 Hierdie dokument is bloot vir rekorddoeleindes in gesondheidverwante gebeurlikhede. Volledigheid is essensieel en die inligting sal konfidensieel hanteer word. / This document is simply for record purposes in the event of a health related situation. Accuracy is essential and the information will be handled as confidential.

InGryp 018 299 1777 (24 uur/hours)

Gesondheidsorgsentrum / Health Care Centre 018 299 4345 (Kantoor ure/Office hours)

NWU Nooddienste / NWU Emergency Services 018 299 2211/5 (24 uur/hours)

Female