GUIDELINES TO FILL IN HEALTH EXAMINATION REPORT

(for International Students)

1. Please read the instructions carefully before filling in the form.

2. Please fill in the form in the English language.

3. Please write in capital letters.

4. This form has 2 sections

- Section 1 (Part A and B) to be filled by the candidates

- Section 2 to be filled by the examining doctor

5. Please complete all the tests required in this form.

6. Please attach all the original laboratory results.

7. Please bring along the chest x-ray film and report.

A. Please ensure the x-ray film is labelled with your name and date taken (in English)

B. Chest x-ray must be done within 3 months prior to registration

8. University only accepts medical examination done within 3 month before registration.

9. University has the right to repeat the medical check-up should there be any doubt of the medical

report. All costs involved will be paid by the candidates.

 FORM G

UNIVERSITI UTARA MALAYSIA

HEALTH EXAMINATION REPORT

(FOR INTERNATIONAL STUDENT)

PLEASE USE CAPITAL LETTERS Passport size

SECTION 1 (To be completed by candidate) photo

(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 .

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

Current medication (Long term)

____________________________________ ___________________________________
____________________________________ ___________________________________
IMMUNIZATION HISTORY (where DATE IMMUNIZED
applicable)
1. Yellow Fever
2. BCG
3. Meningitis (Quadrivalent)
4. Hepatitis B
5. Others:

I hereby certify that the information given above is true. I understand that my application will be rejected if false
information is given.

Date Signature of Candidate

 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
SECTION 3 - INVESTIGATIONS

URINE TEST

ITEM DATE TAKEN RESULT

a. ALBUMIN

b. SUGAR

c. MICROSCOPIC

d. MORPHINE

e. CANNABIS
f. AMPHETAMINES TYPE
STIMULANT

BLOOD TEST

ITEM DATE TAKEN RESULT

a. HEPATITIS Bs ANTIGEN

b. HEPATITIS C

c. HIV

d. VDRL / TPHA

e. MALARIAL PARASITE

CHEST X-RAY INFORMATION

CHEST X-RAY NO.

DATE TAKEN

PLACE TAKEN

REPORT
 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:

IN GOOD HEALTH

HAS MEDICAL PROBLEM (Please State)

____________________________________________________
____________________________________________________
____________________________________________________

IS UNDERGOING TREATMENT FOR: (Please State)

____________________________________________________
____________________________________________________
____________________________________________________

Date Signature of Doctor :

Name of Doctor :
Qualification and :
Official stamp of Clinic

_________________________________________________________________________

Remarks by University Official: