HEALTH EXAMINATION REPORT

Size: px

Start display at page:

Download "HEALTH EXAMINATION REPORT"

Oscar Lambert Rice
5 years ago
Views:

Workstation : IIUM HWC Version : 00 Revision : 00 Effective Date : 1 st December 2018 HEALTH EXAMINATION REPORT (for Malaysian Students) (Please complete Part 1 and 2 only.

BAHAGIAN 1 PART 1 TAHUN AKADEMIK / ACADEMIC YEAR PROGRAM / PROGRAMME SEMESTER / Seperti dalam Surat Tawaran / s in the Offer Letter KULLIYYAH / FACULTY NO. MATRIK / MATRIC NO.

1 Workstation : IIUM HWC Version : 00 Revision : 00 Effective Date : 1 st December 2018 HEALTH EXAMINATION REPORT (for Malaysian Students) (Please complete Part 1 and 2 only. Part 3, 4, 5 is to be filled by the IIUM Medical Officer only) ARAHAN: SILA ISI DALAM HURUF BESAR INSTRUCTION: PLEASE FILL IN CAPITAL LETTERS GAMBAR PASPORT PELAJAR STUDENT S PASSPORT PHOTOGRAPH BAHAGIAN 1 PART 1 TAHUN AKADEMIK / ACADEMIC YEAR PROGRAM / PROGRAMME SEMESTER / Seperti dalam Surat Tawaran / s in the Offer Letter KULLIYYAH / FACULTY NO. MATRIK / MATRIC NO. Seperti dalam Surat Tawaran / As in the Offer Letter NAMA PENUH / FULL NAME NO. KAD PENGENALAN / IDENTITY CARD UMUR / AGE KEWARGANEGARAAN / NATIONALITY TARIKH LAHIR / DATE OF BIRTH D D M M Y Y Y Y LELAKI / MALE PEREMPUAN / FEMALE BUJANG / SINGLE KAHWIN / MARRIED NAMA PENJAGA / NAME OF GUARDIAN ALAMAT PENJAGA / POSTAL ADDRESS OF GUARDIAN NO. TELEFON RUMAH / HOUSE TELEPHONE NO. NO. TELEFON PEJABAT / OFFICE TELEPHONE NO. 1

2 NAMA PENUH / FULL NAME & NO. MATRIK / MATRIC NO. BAHAGIAN 2 Sila tandakan (/) di kotak berkenaan PART 2 Please tick (/) the relevant box Pengakuan mengenai penyakit yang dihadapi sendiri dan ahli keluarga terdekat (ibu, bapa, adik-beradik). Sila jelaskan dengan lanjut sekiranya anda atau ahli keluarga menghadapi penyakit-penyakit berikut:/ Declaration of self and immediate family (Father, mother, siblings) illness. Explain in full if you or your family has any of the following illnesses. NO MEDICAL PROBLEMS (Masalah Kesihatan) SELF IMMEDIATE FAMILY Yes No Yes No If Yes, please state (Jika Ya, sila nyatakan) 1 Congenital or Inherited Disorder (Penyakit Sejak Lahir/Penyakit Keturunan) 2 Allergy (Alergi) 3 Mental Illness (Sakit Jiwa) Fits, Stroke, Other Neurological Disease 4 (Sawan, Strok dan Lain-Lain Penyakit Saraf) 5 Diabetes Mellitus (Kencing Manis) 6 Hypertension (Darah Tinggi) 7 Heart or Vascular Disease (Sakit Jantung) 8 Asthman (Lelah) 9 Thyroid Disease (Sakit Tiroid) 10 Kidney Disease (Sakit Buah Pinggang) 11 Cancer (Kanser) 12 Tuberculosis (Batuk Kering) 13 Drug Addiction (Penyalahgunaan Dadah) 14 AIDS, HIV 15 Epilepsy (Gila Babi) 16 Deformity (Kecacatan) 17 History of Surgery (Sejarah Pembedahan) 18 Other Illnesses (Lain-Lain Penyakit) Saya dengan ini mengaku segala maklumat kesihatan yang diberi di atas adalah benar. / I hereby certify that the information given above is true. Tandatangan Calon / Signature of Candidate. Tarikh / Date 2

3 NAMA PENUH / FULL NAME & NO. MATRIK / MATRIC NO. BAHAGIAN 3 Untuk Diisi Oleh Doktor Yang Memeriksa PART 3 To Be Filled By Examining Doctor Tandakan yang berkaitan / Tick as relevant / 1. PEMERIKSAAN UMUM / GENERAL EXAMINATIONS TINGGI/HEIGHT cm/sm BERAT/WEIGHT kilogram NADI/PULSE seminit/per minute BP / mmhg a. PALLOR b. CYNOSIS c. OEDEMA d. JAUNDICE e. LYMPH NODES f. SKIN 2. PEMERIKSAAN MATA / KANAN/ KIRI CATATAN/ EXAMINATION OF EYE RIGHT LEFT REMARKS a. PENGLIHATAN TANPA KACA MATA/ UNAIDED VISION b. PENGLIHATAN DENGAN KACA MATA/ AIDED VISION c. FUNDOSCOPY NORMAL d. PENGLIHATAN WARNA/ NORMAL COLOUR VISION 3. PEMERIKSAAN TELINGA/ NORMAL EXAMINATION OF EAR 4. RUANG MULUT/ NORMAL ORAL CAVITY 5. JANTUNG/ NORMAL HEART 3

4 NAMA PENUH / FULL NAME & NO. MATRIK / MATRIC NO. 6. a. SISTEM RESPIRATORI / NORMAL RESPIRATORY SYSTEM b. * X-RAY NORMAL LAMPIRKAN X-RAY DADA SERTA LAPORAN (filem besar)/ PLEASE ATTACH CHEST X-RAY AND REPORT (large film) TARIKH X-RAY DIAMBIL/ TEMPAT DIAMBIL/ NO. RUJUKAN X-RAY DATE OF X-RAY TAKEN PLACE TAKEN X-RAY REF. NO. 7. ABDOMEN & RONGGA HERNIA / NORMAL ABDOMEN & HERNIA ORIFICES 8. SISTEM SARAF & MENTAL / NORMAL NERVOUS SYSTEM & MENTAL CONDITION 9. SISTEM MUSKULOSKELETAL/ NORMAL MUSCULOSKELETAL SYSTEM 10. LAIN-LAIN / OTHERS BAHAGIAN 4 / PART4 11. PEMERIKSAAN AIR KENCING / EXAMINATION OF URINE Gula / Sugar Albumin Microscopy 4

5 BAHAGIAN 5 PART 5 PENGESAHAN DOKTOR / Certification by Doctor Sila tandakan (/) di dalam kotak yang berkenaan / Please tick (/) in the appropriate box Saya mengesahkan bahawa pada hari ini saya telah memeriksa / I certify that on this day I have examined dan mendapati bahawa :- and found that :- Beliau tidak mengidapi apa-apa penyakit dan disahkan sihat The above named is in good health Beliau mengidap The above named has Beliau sedang mendapat rawatan The above named is undergoing treatment No. K/P / I/C Tandatangan Doktor : Tarikh / Date : Signature of Doctor Nama Doktor : Name of Doctor Kelulusan dan Cop Rasmi Klinik : _ Qualification /Official stamp of hospital / clinic 5

6 6

MEDICAL CHECK-UP FORM (for Malaysian Students)

MEDICAL CHECK-UP FORM (for Malaysian Students) (Please complete Part 1 and 2 only. Part 3,4,5 is to be filled by the IIUM Medical Officer only) ARAHAN: SILA ISI DALAM HURUF BESAR INSTRUCTION: PLEASE FILL