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Admissions and Enrolment

Initial Teacher Training Form ITT 01

Last updated: 9 February 2022

Statement of medical history for assessment of Teacher Training students

SECTION A and C: To be completed by prospective teacher trainees.
SECTION B: To be completed by our university medical adviser.

This form on completion should be posted to:

Dr R D Hollands
Medical Officer for University of Gloucestershire
Underwood Surgery
139 St Georges Road
Cheltenham GL50 3EQ


Section A This section must be completed in full by candidate.

Date of Birth
Title (Mr/Mrs/Miss/Rev/others):
Other names (in full)
Private Address:

Post Code:
Tel No. (Home)
Present Occupation:

Section B For University of Gloucestershire medical adviser’s use only.

Applicant fit for course
Applicant not fit for course

The University of Gloucestershire seeks to offer a place irrespective of physical or mental disabilities wherever possible, as long as they do not compromise your health, your education, your safety, or the health, safety, and welfare of pupils or trainees likely to be in your care.

The answers to any questions will not be used against you in any course decisions that will be made, either now, or in the future. A decision not to accept you on health grounds will only be taken after very careful consideration of all the fact s and will be based upon individual circumstances and the demands of your teaching career.

Candidates who are refused acceptance onto the course on health grounds have a right to a second opinion from a suitably qualified independent medical examiner.

The information contained on this form will be kept strictly confidential within the Underwood Surgery and will not be used or disclosed to any other persons without the consent of the person to whom the information relates.

Candidates should be aware that if their initial medical questionnaire is not returned by Friday 24 July 20 20 it may not be possible to complete a medical assessment before the beginning of the university year, which will impact on enrolment and access to student finance and resources.

Candidates seeking to appeal against a decision by the medical officer not to allow them to start the course must commence the appeal wihtin five working days or it may not be possible to seek a second opinion before the beginning of the university year.

Name of Applicant:

Section C This section must be completed in full by candidate

1. Do you have a physical or mental health condition, which
substantially affects your ability to carry out normal day-to-day work activities?
2. Are you receiving any medical treatment or have you received any within the last 12 months?
3. Are you awaiting any operations, treatment or
4. Have you had joint or back problems for which you have
sought medical help?
5. Have you received any pension or compensation for work related illness?
6. Do you have any problems with walking, sitting, standing or climbing stairs?
7. Do you have any problems with bending, kneeling, lifting,
carrying or other manual tasks?
8. Do you have any problems with speech, vision, dyslexia,
hearing or communication?
9. Do you have any bladder or bowel problems, which may
require you to have immediate access to toilet facilities?
10. Have you been away from work or absent from studies/
school because of illness in the last 2 years? If so, why and for how long?
11. Have you ever had to change job because of a health
12. Do you have any health problem, which affects your work or leisure pursuits?
13. Do you need or would it assist you to have any special provision made to enable you to fulfil your training and subsequent employment as a teacher
14. Have you had mental ill health, nervous breakdown,
anxiety, depression, or psychiatric problems for which
you have sought medical help?
15. Have you had fits, fainting attacks, blackout s or epilepsy?




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