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    The University of Nottingham Malaysia Campus: Health Examination Report

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    Niyati Barot
    This document is a health examination report form for students attending the University of Nottingham Malaysia Campus. It collects personal information about the student's identity, medical history, family medical history, immunization history, and results of physical examinations, urine tests, blood tests, and chest x-rays. The examining doctor must certify whether the student is in good health, has any medical problems, or is undergoing any medical treatment. The form is used to screen students' medical fitness before they enroll at the university.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    The University of Nottingham Malaysia Campus: Health Examination Report

    Uploaded by

    Niyati Barot
    36 views5 pages
    This document is a health examination report form for students attending the University of Nottingham Malaysia Campus. It collects personal information about the student's identity, medical history, family medical history, immunization history, and results of physical examinations, urine tests, blood tests, and chest x-rays. The examining doctor must certify whether the student is in good health, has any medical problems, or is undergoing any medical treatment. The form is used to screen students' medical fitness before they enroll at the university.

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    Health Examination Report

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    This document is a health examination report form for students attending the University of Nottingham Malaysia Campus. It collects personal information about the student's identity, medical history, family medical history, immunization history, and results of physical examinations, urine tests, blood tests, and chest x-rays. The examining doctor must certify whether the student is in good health, has any medical problems, or is undergoing any medical treatment. The form is used to screen students' medical fitness before they enroll at the university.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    36 views5 pages

    The University of Nottingham Malaysia Campus: Health Examination Report

    Uploaded by

    Niyati Barot
    This document is a health examination report form for students attending the University of Nottingham Malaysia Campus. It collects personal information about the student's identity, medical history, family medical history, immunization history, and results of physical examinations, urine tests, blood tests, and chest x-rays. The examining doctor must certify whether the student is in good health, has any medical problems, or is undergoing any medical treatment. The form is used to screen students' medical fitness before they enroll at the university.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
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    of 5

    Borang RME/IPT Malaysia

    THE UNIVERSITY OF NOTTINGHAM


    MALAYSIA CAMPUS
    HEALTH EXAMINATION REPORT

    PLEASE USE CAPITAL LETTERS


    Section 1 (To be completed by the candidate)
    (PART A)

    Passport size
    photo

    FULL NAME (AS IN PASSPORT)

    INTERNATIONAL PASSPORT NO.


    NATIONALITY

    CONTACT NUMBER

    DATE OF BIRTH
    D

    AGE
    Y

    ACADEMIC YEAR

    SEX
    MALE
    FEMALE

    MARITAL STATUS
    SINGLE
    MARRIED

    COURSE CODE

    SEMESTER

    /
    FACULTY

    MATRIC NO.

    NEXT OF KIN
    NEXT OF KINS ADDRESS

    NEXT OF KINS CONTACT NUMBER

    SECTION 1
    1

    Borang RME/IPT Malaysia

    (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
    FAMILY

    SELF

    MEDICAL PROBLEMS
    YES

    NO

    YES

    If Yes please state.

    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 illness
    Current Medication (Long term)
    ______________________________________

    ________________________________________

    ______________________________________

    ________________________________________

    IMMUNIZATION HISTORY
    (where applicable)

    DATE IMMUNIZED

    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 there is any false
    information given.

    ..
    Date

    ..
    Signature of candidate
    2

    Borang RME/IPT Malaysia

    SECTION 2 -

    PHYSICAL EXAMINATION

    To be filled by examining doctor


    1. BASIC MEASUREMENT
    HEIGHT : ____________________________ m

    BLOOD PRESSURE : ________________________ mmHg

    WEIGHT : ___________________________ kg

    PULSE RATE

    VISION TEST : Unaided : (R) __________ (L) __________

    COLOUR VISION TEST :

    Aided

    : (R) __________ (L) __________

    : ________________________/ min

    NORMAL

    ABNORMAL

    2. GENERAL EXAMINATION
    ITEM

    YES

    NO

    COMMENT

    NORMAL

    ABNORMAL

    COMMENT

    a. DEFORMITIES
    b. PALLOR
    c. CYANOSIS
    d. JAUNDICE
    e. OEDEMA
    f. SKIN DISEASES

    3. SYSTEMIC EXAMINATION
    ITEM
    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
    h. MUSCULOSKELETAL SYSTEM

    Borang RME/IPT Malaysia

    SECTION 3 - INVESTIGATIONS
    URINE TEST
    ITEM

    DATE TAKEN

    RESULT

    DATE TAKEN

    RESULT

    a. ALBUMIN
    b. SUGAR
    c. MICROSCOPIC
    d. MORPHINE
    e. CANNABIS
    f. AMPHETAMINES TYPE
    STIMULANT

    BLOOD TEST
    ITEM
    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

    Borang RME/IPT Malaysia

    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

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