GUIDELINES TO FILL IN HEALTH EXAMINATION REPORT
HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS
1. 2. 3. 4.
PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE FILLING IN THE FORM. PLEASE FILL IN THE FORM IN ENGLISH LANGUAGE. PLEASE WRITE IN CAPITAL LETTERS. THIS FORM HAS 4 SECTIONS: (a) (b) SECTION 1 (PART A AND B) TO BE FILLED BY THE APPLICANT; AND SECTION 2, 3 AND 4 TO BE FILLED BY THE EXAMINING DOCTOR
5. 6.
PLEASE COMPLETE ALL THE TESTS REQUIRED IN THIS FORM. THE UNIVERSITY / COLLEGE ONLY ACCEPT MEDICAL EXAMINATION DONE WITHIN 60 DAYS BEFORE REGISTRATION.
7. 8. 9.
PLEASE ATTACH ALL THE ORIGINAL LABORATORY RESULTS. PLEASE BRING ALONG CHEST X-RAY FILM AND REPORT FOR REGISTRATION AT KDU COLLEGE. 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/ COLLEGE RESERVES THE RIGHT TO REPEAT FULL MEDICAL CHECKUP OR ANY SPECIFIC LABORATORY TESTS SHOULD THERE BE ANY DOUBT IN THE MEDICAL REPORT SUBMITTED. ALL COSTS INVOLVED SHALL BE BORNE BY THE CANDIDATES. 12. THE UNIVERSITY/ COLLEGE RESERVES THE RIGHT TO REJECT ANY APPLICATION: (a) (b) BASED ON THE RESULTS OF THE HEALTH EXAMINATION; OR SHOULD THERE BE ANY EVIDENCE THAT THE APPLICANT HAS GIVEN FALSE INFORMATION IN THE HEALTH EXAMINATION REPORT OR ANY SUPPORTING DOCUMENTS.
H.E.R/IPT MALAYSIA/KDU
KDU COLLEGE SDN BHD SS22/41 DAMANSARA JAYA 47400 PETALING JAYA, SELANGOR. TEL:03-7728 8123 FAX:03-7726 6941 www.kdu.edu.my HEALTH EXAMINATION REPORT FOR INTERNATIONAL STUDENT & ACCOMPANYING PERSON PLEASE USE CAPITAL LETTERS SECTION 1 (To be completed by candidate) (PART A) Passport size photo
FULL NAME (AS IN PASSPORT)
INTERNATIONAL PASSPORT NO.
NATIONALITY
CONTACT NUMBER
DATE OF BIRTH D D M M Y Y
AGE
SEX MALE FEMALE KDU STUDENT NO.
MARITAL STATUS SINGLE MARRIED
ACADEMIC YEAR / PROGRAMME OF STUDY
PROGRAMME CODE
NEXT OF KIN
NEXT OF KINS ADDRESS
NEXT OF KINS 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. SELF MEDICAL PROBLEMS Yes 1. Congenital or inherited disorder 2. Allergy No
IMMEDIATE FAMILY
If Yes please state
Yes
No
H.E.R/IPT MALAYSIA/KDU
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 applicable) 1. 2. 3. 4. 5. Yellow Fever BCG Meningitis (Quadrivalent) Hepatitis B 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 SECTION 2 - PHYSICAL EXAMINATION (To be filled by examining doctor) 1. BASIC MEASUREMENT HEIGHT : __________________ m WEIGHT : __________________ kg VISION TEST : Unaided : (R) _______ (L) ________ Aided : (R) _______ (L) ________ BLOOD PRESSURE : ______________ mmHg PULSE RATE : ______________ / min Signature of candidate DATE IMMUNIZED
COLOUR VISION TEST : NORMAL / ABNORMAL
2. GENERAL EXAMINATION ITEM a. DEFORMITIES YES NO COMMENT
H.E.R/IPT MALAYSIA/KDU
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 NORMAL ABNORMAL COMMENT
g. LUNGS h. ABDOMEN / HERNIA ORIFICES i. j. NERVOUS SYSTEM MENTAL CONDITION
k. MUSCULOSKELETAL SYSTEM SECTION 3 URINE TEST ITEM a. b. c. d. e. f. ALBUMIN SUGAR MICROSCOPIC MORPHINE CANNABIS AMPHETAMINES TYPE STIMULANT DATE TAKEN RESULT INVESTIGATIONS
BLOOD TEST ITEM a. b. HEPATITIS Bs ANTIGEN HEPATITIS C DATE TAKEN RESULT
H.E.R/IPT MALAYSIA/KDU
c. d. e.
HIV VDRL / TPHA 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 HAVING THE FOLLOWING MEDICAL COMPLICATION(S) : (Please State)
_________________________________________________________________ _________________________________________________________________
UNDERGOING TREATMENT FOR : (Please State)
_______________________________________________________________ _______________________________________________________________
Date Signature of Doctor Name of Doctor Qualification Hospital / Clinic Registration Number Official stamp : : : :
_________________________________________________________________________________________________________________________________________________ Remarks By University/College Official :
H.E.R/IPT MALAYSIA/KDU
