Adalah: (A) : Form Pd1

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FORM PD1

MAKLUMAT PENTING

• Pemeriksaan Kesihatan adalah WAJIB bagi semua pelajar baharu.

• Pemeriksaan Kesihatan boleh dilakukan di mana-mana Hospital/Klinik Kerajaan


atau Hospital/Klinik Swasta.

• Pelajar dikehendaki mencetak dan melengkapkan borang maklumat yang telah


dimuat turun.

• Borang Pemeriksaan Kesihatan (Borang PD1) mempunyai EMPAT (4) Seksyen.

(a) Seksyen 1 (Bahagian A, B dan C)– diisi oleh pelajar


(b) Seksyen 2, 3 dan 4 – diisi oleh Pegawai Perubatan

• Dokumen yang perlu dibawa pada hari penyerahan yang ditetapkan adalah:

(a) Borang Laporan Pemeriksaan Perubatan (FORM PD1)


(b) laporan X-ray dada dan keputusan ujian urin (ASAL).
(c) keputusan ujian darah dan keputusan saringan tuberculosis
(bagi pelajar FAKULTI PERUBATAN, PERGIGIAN DAN
FARMASI sahaja)

• Sebarang pertanyaan boleh hubungi talian : 03-79676445/6444

UM-PT07-PK01-BR032-S03 1
FORM PD1

IMPORTANT INFORMATION

• The medical examination is COMPULSORY for all new students.

• The medical check-up can be done at Government Hospital/Clinic or Private


Hospital/Clinic

• The student requires to print and complete the form.

• The medical examination form (PD1 Form) has 4 Sections :

(a) Section 1 (Part A, B and C) - to be completed by candidate


(b) Section 2, 3 and 4 – to be filled by Medical Officer

• As part of your enrollment to the University, all new students are required to submit
important documents as below:

(a) Medical Examination Report (PD1 FORM)


(b) Chest x –ray report and Laboratory report (original)
(c) blood test result and tuberculosis screening result (for MEDICAL,
DENTAL AND PHARMACY STUDENT only)

• Any inquiries, kindly contact Tel : 03-79676445/6444

UM-PT07-PK01-BR032-S03 2
FORM PD1

UNIVERSITI MALAYA
LAPORAN PEMERIKSAAN PERUBATAN
MEDICAL EXAMINATION REPORT

SILA ISI MENGGUNAKAN HURUF BESAR


(PLEASE USE CAPITAL LETTERS)
Gambar ukuran
SEKSYEN 1 – Untuk Diisi Oleh Calon paspot
(SECTION 1 (To Be Completed By Candidate)) (Passport size
photo)

BAHAGIAN A
(PART A)

NAMA PENUH / FULL NAME

KEWARGANEGARAAN / NATIONALITY

NO. KAD PENGENALAN/NO. PASSPORT / IDENTITY CARD NO. TELEFON / CONTACT NO.
NO. / PASSPORT NO.

TARIKH LAHIR / UMUR / JANTINA / STATUS PERKAHWINAN /


DATE OF BIRTH AGE GENDER MARITAL STATUS
BUJANG SINGLE
L/ M
KAHWIN /MARRIED
D D M M Y Y P/ F

FAKULTI / FACULTY NO. MATRIK / MATRIC NO./

NAMA SAUDARA TERDEKAT / PENJAGA / NEXT OF KIN’S / GUARDIAN’S NAME

ALAMAT SAUDARA TERDEKAT / NEXT OF KIN’S ADDRESS

NO. TELEFON SAUDARA TERDEKAT / NEXT OF KIN’S CONTACT NUMBER (UNTUK


KECEMASAN/FOR EMERGENCY)

HUBUNGAN / RELATIONSHIP

UM-PT07-PK01-BR032-S03 3
FORM PD1
BAHAGIAN B - Sila tandakan (√) dalam kotak yang berkenaan
(PART B - Please tick (√) in the relevant box.)

Pengisytiharan tahap kesihatan diri sendiri (Declaration of self illness).

1. Adakah anda mengidap sebarang penyakit?


Do you have any medical illness?
Ya, nyatakan / Yes, please state Tidak / No

2. Adakah anda mengambil sebarang ubat untuk penyakit yang dinyatakan di atas?
Are you currently taking any medication for the illness stated above?
Ya, nyatakan / Yes, please state Tidak / No

3. Adakah anda pernah menjalani sebarang pembedahan?


Have you had any surgery before?
Ya, nyatakan / Yes, please state Tidak / No

4. Adakah anda mempunyai sebarang kecacatan?


Do you have any disability?
Ya, nyatakan / Yes, please state Tidak / No

5. Adakah anda mempunyai masalah kesihatan mental?


Do you have any problem with mental illness?
Ya, nyatakan / Yes, please state Tidak / No

UM-PT07-PK01-BR032-S03 4
FORM PD1

6. Maklumat tentang tabiat merokok.


Information regarding smoking habit.
Perokok / Smoker Tidak merokok / Non smoker

Bilangan rokok/hari / Number of cigarette/day

Telah berhenti merokok / Ex-smoker


Bila berhenti / When do you quit?
(Tahun / Year)

BAHAGIAN C - Sila tandakan (√) dalam kotak yang berkenaan


(PART C - Please tick (√) in the relevant box.)

SEJARAH IMUNISASI TARIKH VAKSINASI


IMMUNISATION HISTORY DATE OF VACCINATION
BCG
Pertussis
Poliovirus
Diphtheria
Tetanus
Mumps
Rubella
Measles
Hepatitis B
Varicella (Chicken Pox)
Meningococcal ACWY
COVID-19 Vaccine

*any other vaccines will be added as determined by University Malaya from time to time

Saya dengan ini mengesahkan bahawa maklumat di atas adalah benar. Saya sedia maklum
bahawa permohonan saya akan ditolak sekiranya maklumat yang diberikan adalah tidak
benar. Saya dengan ini memberi keizinan agar laporan perubatan ini diserahkan kepada
pihak universiti.
(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. I hereby give my consent for this
medical report to be submitted to the university.)

...................................... ...........................................
Tarikh / Date Tandatangan calon /
Signature of candidate

UM-PT07-PK01-BR032-S03 5
FORM PD1

Name: …………………………………….
IC No: …………………………………….

SECTION 2 - PHYSICAL EXAMINATION


To be filled by examining doctor

1. BASIC MEASUREMENT
HEIGHT : m BLOOD PRESSURE : mmHg
WEIGHT : kg PULSE RATE : / min
BMI : kg/m2 WAIST CIRCUMFERENCE : cm

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 fundus copy)

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

UM-PT07-PK01-BR032-S03 6
FORM PD1
Name: …………………………………….
IC No: …………………………………….

SECTION 3 - INVESTIGATIONS

Part 1A: (FOR ALL STUDENT)

URINE TEST
ITEM DATE TAKEN RESULT

a. ALBUMIN

b. SUGAR

Part 1B: (FOR ALL STUDENT)

CHEST X-RAY INFORMATION


CHEST X-RAY NO.

DATE TAKEN

PLACE TAKEN

REPORT*

*SILA LAMPIRKAN LAPORAN ASAL KEPUTUSAN UJIAN.


*PLEASE ATTACH ORIGINAL TEST RESULT.

UM-PT07-PK01-BR032-S03 7
FORM PD1

Name: …………………………………….
IC No: …………………………………….

Part 2: (FOR INTERNATIONAL STUDENT ONLY)

URINE FOR DRUGS


ITEM DATE TAKEN RESULT

a. MORPHINE

b. CANNABIS

c. AMPHETAMINES TYPE
STIMULANT
BLOOD TEST
ITEM DATE TAKEN RESULT
a. HEPATITIS Bs ANTIGEN

b. HEPATITIS Bs ANTIBODY

c. HEPATITIS C

d. VDRL / TPHA

e. HIV

f. MALARIAL PARASITE (BFMP)


SILA LAMPIRKAN LAPORAN ASAL KEPUTUSAN UJIAN.
PLEASE ATTACH ORIGINAL TEST RESULT.

Part 3: (FOR MEDICAL/DENTAL/PHARMACY STUDENT ONLY)

BLOOD TEST
ITEM DATE TAKEN RESULT

a. HEPATITIS Bs ANTIGEN

b. HEPATITIS Bs ANTIBODY

c. HIV
MANTOUX TEST

ITEM DATE TAKEN RESULT

a. MANTOUX TEST
(TUBERCULOSIS
SCREENING)

SILA LAMPIRKAN LAPORAN ASAL KEPUTUSAN UJIAN.


PLEASE ATTACH ORIGINAL TEST RESULT.

UM-PT07-PK01-BR032-S03 8
FORM PD1

Name: …………………………………….
IC No: …………………………………….

SECTION 4 - CERTIFICATION BY THE EXAMINING DOCTOR

I hereby certify that I have examined with


ID No. / Passport No. on this date 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 &:
Official stamp of Clinic

Remarks by University Official:

UM-PT07-PK01-BR032-S03 9

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