HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS
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1 HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS LAMPIRAN A 1. PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE FILLING IN THE FORM. 2. PLEASE FILL IN THE FORM IN ENGLISH LANGUAGE. 3. PLEASE WRITE IN CAPITAL LETTERS. 4. THIS FORM HAS 4 SECTIONS: a) SECTION 1 (PART A AND B) TO BE FILLED BY THE APPLICANT; AND b) SECTION 2, 3 AND 4 TO BE FILLED BY THE EXAMINING DOCTOR 5. PLEASE COMPLETE THE ENTIRE TESTS REQUIRED IN THIS FORM. 6. THE UNIVERSITY / COLLEGE ONLY ACCEPTS MEDICAL EXAMINATION DONE WITHIN 90 DAYS BEFORE ARRIVAL IN MALAYSIA. 7. PLEASE ATTACH ALL THE ORIGINAL LABORATORY RESULTS. 8. PLEASE BRING ALONG CHEST X-RAY FILM (OR DIGITAL IMAGES) AND REPORT FOR REGISTRATION, FOR THE PURPOSE OF VERIFICATION, IF NECESSARY. 9. PLEASE ENSURE THE X-RAY FILM OR DIGITAL IMAGES ARE 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 CHECK-UP 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) BASED ON THE RESULTS OF THE HEALTH EXAMINATION; OR (b) SHOULD THERE BE ANY EVIDENCE THAT THE APPLICANT HAS GIVEN FALSE INFORMATION IN THE HEALTH EXAMINATION REPORT OR ANY SUPPORTING DOCUMENTS.
2 HEALTH EXAMINATION REPORT FOR INTERNATIONAL STUDENT Passport size photo PLEASE USE CAPITAL LETTERS SECTION 1 - PERSONAL DETAILS To be completed by candidate (PART A) Please write and/ or tick ( ) in the relevant box FULL NAME (AS IN PASSPORT) INTERNATIONAL PASSPORT NO. BLOOD GROUP (RHESUS) NATIONALITY CONTACT NUMBER DATE OF BIRTH AGE SEX MARITAL STATUS MALE SINGLE D D M M Y Y FEMALE MARRIED ACADEMIC YEAR / STUDENT ID PROGRAMME OF STUDY PROGRAMME CODE NEXT OF KIN NEXT OF KIN S ADDRESS NEXT OF KIN S CONTACT NUMBER. 1
3 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 MEDICAL PROBLEMS 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 Diseases 10. Kidney Diseases 11. Cancer 12. History of Surgery 13. Tuberculosis (TB) 14. HIV/ AIDS 15. Hepatitis B 16. Sexually Transmitted Diseases 17. Drug Addiction 18. Other Illnesses SELF IMMEDIATE FAMILY Yes No Yes No If Yes please state. Current medication (Long term) 2
4 VACCINATION HISTORY (where applicable) 1. Yellow Fever* DATE OF VACCINATION 2. BCG 3. Meningitis (Quadrivalent) 4. Hepatitis B 5. Polio 6. Measles 7. Rubella 8. Others: (please specify) Notes: 1. *A valid Yellow Fever vaccination certificate is required from all travelers coming from or transited more than 12 hours through countries with risk of Yellow Fever transmission. 2. All students are required to take vaccines as listed in numbers 2-7 above. 3. The students are required to bring along the International Certificate of Vaccination or Prophylaxis with them for verification of information. 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 3
5 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/m 2 ) 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 1. EYES (including funduscopy) 2. EARS 3. NOSE 4. ORAL CAVITY / THROAT 5. NECK 6. CARDIOVASCULAR 7. RESPIRATORY 8. ABDOMEN INCLUDING HERNIA ORIFICES 9. NERVOUS SYSTEM 10.MENTAL STATUS 11.MUSCULOSKELETAL SYSTEM 4
6 SECTION 3 - INVESTIGATIONS URINE TEST a. ALBUMIN b. SUGAR c. MICROSCOPIC d. OPIATES (INCLUDING CODEIN, MORPHINE, HEROIN) e. CANNABINOIDS ITEM DATE TAKEN RESULT f. AMPHETAMINES TYPE STIMULANT (ATS) BLOOD TEST ITEM DATE TAKEN RESULT a. HEPATITIS Bs ANTIGEN b. HIV ANTIBODY c. VDRL / TPHA* d. MALARIAL PARASITES * TPHA is done if VDRL is reactive. ** all test results/ reports is valid for 3 months CHEST X-RAY INFORMATION DATE TAKEN CHEST X-RAY NO. X-RAY FACILITY 5
7 X-RAY REPORT: ABNORMAL NORMAL DETAILS OF ABNORMALITY 1. Thoracic Cage 2. Heart Shape and Size (CTR > 0.55 and in failure OR significant cardiomegaly) 3. Lung Fields 4. Mediastinum and Hilar 5. Pleura/ Hemidiaphragms/ Costopherenic Angles YES NO DETAILS OF ABNORMALITY 6. Focal Lesion (E.g. Old/ New PTB, Tumour) 7. Any other Abnormalities 8. Impression 6
8 SECTION 4 - CERTIFICATION BY THE EXAMINING DOCTOR Please write and/ or 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) YES NO 1. HIV 2. HEPATITIS B 3. TUBERCULOSIS 4. MALARIA 5. TIFOID 6. SEXUALLY TRANSMITTED DISEASES 7. PSYCHIATRIC DISORDERS 8. EPILEPSY 9. OTHERS (Please specify under comments) 7
9 I ALSO FIND THAT: POSITIVE NEGATIVE 10. His/ her urine for amphetamine type stimulants (ATS) (screening test) 11. His/ her urine for opiates (screening test) 12. His/ her urine for cannabinoids (screening test) HEREBY, THE STUDENT IS SUITABLE/ UNSUITABLE FOR STUDY (COURSE) IN MALAYSIA: Date: Signature of Doctor: Name of Doctor: Qualification: Hospital/ clinic Registration Number: Official stamp: Remarks by University/ College Official : 8
HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS
LAMPIRAN A HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS 1. PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE FILLING IN THE FORM. 2. PLEASE FILL IN THE FORM IN ENGLISH
HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS
HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS 1. PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE FILLING IN THE FORM. 2. PLEASE FILL IN THE FORM IN ENGLISH LANGUAGE.
HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS
HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS 1. PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE FILLING IN THE FORM. 2. PLEASE FILL IN THE FORM IN ENGLISH LANGUAGE.
HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS
HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS 1. PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE FILLING IN THE FORM. 2. PLEASE FILL IN THE FORM IN ENGLISH LANGUAGE
HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS
HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS 1. PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE FILLING IN THE FORM. 2. PLEASE FILL IN THE FORM IN ENGLISH LANGUAGE.
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Date: Date of Birth: Age: Sex: Male Female Address: City: State: Zip: Telephone: Email: PREFFERED PHARMACY NAME & LOCATION: PRIMARY PHYSICIAN: SPECIALISTS: INSURANCE GoPrivateMD will not bill your insurance.
APPLICATION PACK CHECKLIST
APPLICATION PACK CHECKLIST Instructions Please tick if the relevant section is completed and included: Employment Application WorkCover Declaration Immunisation Record Form Record of Vaccinations Received
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
Student Health Services Office 5400 Ramsey Street Fayetteville, North Carolina Phone: (910) or (910) FAX: (910)
1 Last Name: First Name: MU Student ID#: Student Phone #: Year Attending: Fall Spring Year Attended if Returning Student Student Athlete: y/n Sport: International Student: y/n Physician Assistant Student:
Arcana Center for Integrative Medicine
Arcana Center for Integrative Medicine Patient s Name: Date of Birth: Reason for today s visit: Past Medical History Primary care physician: Date of last exam: (sick or well) Physician s Address: Office
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -ORTHO Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
CLINICAL PREPAREDNESS PERMIT
Students are required to: CLINICAL PREPAREDNESS PERMIT Last Name First Name College Student # Birth Date (DD/MM/YY) College Email Address York University Student # Program Intake Date (DD/MM/YY) York University
Washington & Jefferson College Report of Medical History
Report of Medical History To t h e St u d e n t: Please complete this side before going to your physician for examination. The reverse side is to be completed by your physician. This information is strictly
Southern Maine Integrative Health Center Adult Intake Form
Southern Maine Integrative Health Center Adult Intake Form Patient Name: Address: Birthdate: / / Age: / / City: State/Zip: Home Telephone: ( ) Work Telephone: ( ) Employer: Cell phone: ( ) Email Address:
Liver Health: Do you have liver problems? Yes No If so, please specify:
Medical History General Last Name: First Name: Date of Birth: Age: Contact Number: Are you in good health to the best of your knowledge Medical Information: Please list any physicians you see and their
Required Health Records for all Students
Required Health Records for all Students Failure to complete all required forms and immunizations will prohibit you from registering for classes or attending clinical rotation Health Records Specialist
THE KEATS GROUP PRACTICE REGISTRATION FORM PLEASE COMPLETE IN BLOCK CAPITALS PERSONAL BACKGROUND INFORMATION
Registration checked by: Date: 11 & Under THE KEATS GROUP PRACTICE REGISTRATION FORM PLEASE COMPLETE IN BLOCK CAPITALS PERSONAL BACKGROUND INFORMATION Male Female Has your child ever been treated at this
Following this letter are health forms for parents or legal guardians to complete and sign. Please note that:
Summer Pre-College Programs Dear Summer Pre-College Student and Family, Welcome to Marist College! Please review the attached Health Forms. Students will be informed of health and emergency information
Prior to starting at the University of the Pacific, there are several health clearance requirements that need to be completed.
Academic Year 2018/2019 Dear Dental Student: Please read this packet carefully. It contains critical information for your success as a student. It is our pleasure to welcome you to the University of the
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY NAME: _ DATE: Please complete the following questionnaire as completely as possible. 1. MEDICAL HISTORY Please list all current and prior health problems,