Adalah: (A) : Form Pd1
Adalah: (A) : Form Pd1
Adalah: (A) : Form Pd1
MAKLUMAT PENTING
• Dokumen yang perlu dibawa pada hari penyerahan yang ditetapkan adalah:
UM-PT07-PK01-BR032-S03 1
FORM PD1
IMPORTANT INFORMATION
• As part of your enrollment to the University, all new students are required to submit
important documents as below:
UM-PT07-PK01-BR032-S03 2
FORM PD1
UNIVERSITI MALAYA
LAPORAN PEMERIKSAAN PERUBATAN
MEDICAL EXAMINATION REPORT
BAHAGIAN A
(PART A)
KEWARGANEGARAAN / NATIONALITY
NO. KAD PENGENALAN/NO. PASSPORT / IDENTITY CARD NO. TELEFON / CONTACT NO.
NO. / PASSPORT NO.
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.)
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
UM-PT07-PK01-BR032-S03 4
FORM PD1
*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: …………………………………….
1. BASIC MEASUREMENT
HEIGHT : m BLOOD PRESSURE : mmHg
WEIGHT : kg PULSE RATE : / min
BMI : kg/m2 WAIST CIRCUMFERENCE : cm
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
b. EARS
c. NOSE
e. NECK
f. HEART
g. LUNGS
i. NERVOUS SYSTEM
j. MENTAL CONDITION
k. MUSCULOSKELETAL SYSTEM
UM-PT07-PK01-BR032-S03 6
FORM PD1
Name: …………………………………….
IC No: …………………………………….
SECTION 3 - INVESTIGATIONS
URINE TEST
ITEM DATE TAKEN RESULT
a. ALBUMIN
b. SUGAR
DATE TAKEN
PLACE TAKEN
REPORT*
UM-PT07-PK01-BR032-S03 7
FORM PD1
Name: …………………………………….
IC No: …………………………………….
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
BLOOD TEST
ITEM DATE TAKEN RESULT
a. HEPATITIS Bs ANTIGEN
b. HEPATITIS Bs ANTIBODY
c. HIV
MANTOUX TEST
a. MANTOUX TEST
(TUBERCULOSIS
SCREENING)
UM-PT07-PK01-BR032-S03 8
FORM PD1
Name: …………………………………….
IC No: …………………………………….
IN GOOD HEALTH
UM-PT07-PK01-BR032-S03 9