Annexure 10
HEALTH STATUS FORM
MBA Batch 2019-21
1. CAT Reg. No.
2. Name of the student
3. Contact Number of Student
4. Mother’s Name
5. Father’s Name
6. Contact Number of Mother/ Father
7. Description of Medical Condition
8. Name and details of consulting doctor
9. Current prescribed medication
10. Does the condition presents with any
emergency scenario? If yes, details
thereof and suggest measures to be
taken at that time
11. Any support expected from
the Institute to overcome the challenges
faced due to such medical condition
For Office Use: Remarks
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(Signature of the student, with date)