Attachment E-Health Examination Report

UKM-SPKP-PKes-PK01-BO06 No.
Semakan: 02 Tarikh Kuatkuasa:27/10/2016
BORANG PEMERIKSAAN KESIHATAN PELAJAR ANTARABANGSA
HEALTH EXAMINATION GUIDELINES

FOR ENTRY INTO
MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS
1. PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE FILLING IN THE FORM.
2. PLEASE FILL IN THE FORM IN ENGLISH LANGUAGE.
3. PLEASE WRITE IN CAPITAL LETTERS.
4. THIS FORM HAS 4 SECTIONS:

(a) SECTION 1 (PART A AND B) IS TO BE FILLED BY THE CANDIDATES
(b) SECTION 2, 3 AND 4 IS TO BE FILLED BY THE EXAMINING DOCTOR
5. PLEASE COMPLETE ALL THE TESTS REQUIRED IN THIS FORM.
6. THE UNIVERSITY ACCEPTS MEDICAL EXAMINATION DONE WITHIN 60 DAYS BEFORE

REGISTRATION OR WITHIN 30 DAYS AFTER REGISTRATION IN MALAYSIA ONLY.
7. PLEASE ATTACH ALL THE ORIGINAL LABORATORY RESULTS.
8. PLEASE BRING ALONG CHEST X-RAY FILM AND REPORT FOR REGISTRATION.
9. PLEASE ENSURE THE X-RAY FILM IS LABELLED WITH YOUR NAME AND DATE TAKEN
(IN ENGLISH).
10. CHEST X-RAY DONE WITHIN 6 MONTHS PRIOR TO REGISTRATION CAN BE

ACCEPTED.
11. THE UNIVERSITY HAS THE RIGHT TO REPEAT FULL MEDICAL CHECK-UP OR ANY
SPECIFIC LABORATORY TESTS IF THERE IS ANY DOUBT IN THE MEDICAL REPORT.
ALL COSTS INVOLVED SHALL BE BORNE BY THE CANDIDATES.
12. THE UNIVERSITY HAS THE RIGHT TO REJECT ANY APPLICATION:

(a) BASED ON THE RESULTS OF THE HEALTH EXAMINATION
(b) IF THE APPLICANT HAS GIVEN FALSE INFORMATION IN THE HEALTH
EXAMINATION REPORT OR ANY SUPPORTING DOCUMENTS.
UKM-SPKP-PKes-PK01-BO06 No. Semakan: 02 Tarikh Kuatkuasa:27/10/2016
UNIVERSITI KEBANGSAAN MALAYSIA

The National University of Malaysia
HEALTH EXAMINATION REPORT

FOR INTERNATIONAL STUDENT
Passport size
PLEASE USE CAPITAL LETTERS photo
SECTION 1 (To be completed by candidate)

(PART A)
FULL NAME (AS IN PASSPORT)
INTERNATIONAL PASSPORT NO.
NATIONALITY CONTACT NUMBER
DATE OF BIRTH AGE SEX MARITAL STATUS

MALE SINGLE
D D M M Y Y FEMALE MARRIED
ACADEMIC YEAR COURSE CODE SEMESTER

/
FACULTY MATRIC. NO
NEXT OF KIN
NEXT OF KIN’S ADDRESS
NEXT OF KIN’S CONTACT NUMBER .
[1]
SECTION 1
(PART B) – Please tick ( √ ) in the relevant box
Declaration of self and family illness. Explain in full if you or your family has any of the following illnesses.
* Immediate family refers to father, mother, brothers / sisters
IMMEDIATE
SELF
MEDICAL PROBLEMS FAMILY If “Yes” please state.
Yes No Yes No
1. Congenital or inherited disorder
2. Allergy
3. Mental illness
4. Fits, stroke, other neurological disease
5. Diabetes Mellitus
6. Hypertension
7. Heart or vascular disease
8. Asthma
9. Thyroid disease
10. Kidney disease
11. Cancer
12. Tuberculosis
13. Drug addiction
14. AIDS / HIV
15. History of surgery
16. Other illnesses
17. Smoker
18. Hepatitis B / Hepatitis C
Current medication (Long term)

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
I hereby certify that the information given above is true. I understand that my application will be rejected
if there is any false information given.
Date Signature of candidate
[2]

SECTION 2 - PHYSICAL EXAMINATION
To be filled by examining doctor
1. BASIC MEASUREMENT
HEIGHT : __________________ m BLOOD PRESSURE : ______________ mmHg
WEIGHT : __________________ kg PULSE RATE : ______________ / min
VISION TEST : Unaided : (R) _______ (L) ________ COLOUR VISION TEST :
Aided : (R) _______ (L) ________ NORMAL / ABNORMAL
2. GENERAL EXAMINATION
ITEM YES NO COMMENT
a. DEFORMITIES
b. PALLOR
c. CYANOSIS
d. JAUNDICE
e. OEDEMA
f. SKIN DISEASES
3. SYSTEMIC EXAMINATION
ITEM NORMAL ABNORMAL COMMENT
a. EYES (including funduscopy)
b. EARS
c. NOSE
d. ORAL CAVITY / THROAT
e. NECK
f. HEART
g. LUNGS
h. ABDOMEN / HERNIA ORIFICES
i. NERVOUS SYSTEM
j. MENTAL CONDITION
k. MUSCULOSKELETAL SYSTEM
[3]

SECTION 3 - INVESTIGATIONS
URINE TEST
ITEM DATE TAKEN RESULT
a. ALBUMIN
b. SUGAR
c. MICROSCOPIC
d. MORPHINE
e. CANNABIS
f. AMPHETAMINE TYPE
STIMULANTS
* Please attach all the original laboratory results
BLOOD TEST
ITEM DATE TAKEN RESULT
a. HEPATITIS Bs ANTIGEN
b. HEPATITIS B ANTIBODY
c. HEPATITIS C
d. HIV Ag/Ab
e. VDRL / TPHA
f. MALARIAL PARASITE
* Please attach all the original laboratory results
CHEST X-RAY INFORMATION

CHEST X-RAY NO.
DATE TAKEN
PLACE TAKEN
REPORT
[4]

SECTION 4 - CERTIFICATION BY THE EXAMINING DOCTOR
Please tick (√) in the appropriate box :
I certify that I have on this date ___________________ examined

Mr / Ms ___________________________________ Passport No. ____________________
and found him / her :-
THE ABOVE NAMED IS IN GOOD HEALTH
THE ABOVED NAMED HAS THE FOLLOWING MEDICAL PROBLEM

(Please State)
____________________________________________________
____________________________________________________
____________________________________________________
THE ABOVE NAMED IS UNDERGOING TREATMENT FOR:

(Please State)
____________________________________________________
____________________________________________________
____________________________________________________
Date : Signature of Doctor :
Name of Doctor :
Qualification :
Hospital/Clinic :
Dr.’s Registration Number
Official stamp :
_________________________________________________________________________
Remarks By University Official :
[5]

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UKM-SPKP-PKes-PK01-BO06 No.

Semakan: 02 Tarikh Kuatkuasa:27/10/2016

BORANG PEMERIKSAAN KESIHATAN PELAJAR ANTARABANGSA

HEALTH EXAMINATION GUIDELINES

1. PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE FILLING IN THE FORM.

2. PLEASE FILL IN THE FORM IN ENGLISH LANGUAGE.

3. PLEASE WRITE IN CAPITAL LETTERS.

4. THIS FORM HAS 4 SECTIONS:

5. PLEASE COMPLETE ALL THE TESTS REQUIRED IN THIS FORM.

6. THE UNIVERSITY ACCEPTS MEDICAL EXAMINATION DONE WITHIN 60 DAYS BEFORE

7. PLEASE ATTACH ALL THE ORIGINAL LABORATORY RESULTS.

10. CHEST X-RAY DONE WITHIN 6 MONTHS PRIOR TO REGISTRATION CAN BE

12. THE UNIVERSITY HAS THE RIGHT TO REJECT ANY APPLICATION:

BORANG PEMERIKSAAN KESIHATAN PELAJAR ANTARABANGSA

UNIVERSITI KEBANGSAAN MALAYSIA

HEALTH EXAMINATION REPORT

SECTION 1 (To be completed by candidate)

FULL NAME (AS IN PASSPORT)

INTERNATIONAL PASSPORT NO.

NATIONALITY CONTACT NUMBER

DATE OF BIRTH AGE SEX MARITAL STATUS

ACADEMIC YEAR COURSE CODE SEMESTER

NEXT OF KIN’S ADDRESS

NEXT OF KIN’S CONTACT NUMBER .

BORANG PEMERIKSAAN KESIHATAN PELAJAR ANTARABANGSA

4. Fits, stroke, other neurological disease

7. Heart or vascular disease

10. Kidney disease

13. Drug addiction

14. AIDS / HIV

15. History of surgery

16. Other illnesses

18. Hepatitis B / Hepatitis C

Current medication (Long term)

Date Signature of candidate

BORANG PEMERIKSAAN KESIHATAN PELAJAR ANTARABANGSA

Aided : (R) _______ (L) ________ NORMAL / ABNORMAL

a. EYES (including funduscopy)

d. ORAL CAVITY / THROAT

h. ABDOMEN / HERNIA ORIFICES

BORANG PEMERIKSAAN KESIHATAN PELAJAR ANTARABANGSA

CHEST X-RAY INFORMATION

BORANG PEMERIKSAAN KESIHATAN PELAJAR ANTARABANGSA

Please tick (√) in the appropriate box :

I certify that I have on this date ___________________ examined

THE ABOVE NAMED IS IN GOOD HEALTH

THE ABOVED NAMED HAS THE FOLLOWING MEDICAL PROBLEM

THE ABOVE NAMED IS UNDERGOING TREATMENT FOR:

Date : Signature of Doctor :

Remarks By University Official :

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Aided : (R) _ (L) __ NORMAL / ABNORMAL