HEALTH EXAMINATION GUIDELINES
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1 HEALTH EXAMINATION GUIDELINES 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 2 SECTIONS - SECTION 1 (PART A AND B) TO BE FILLED BY THE CANDIDATES - SECTION 2 TO BE FILLED BY THE EXAMINING DOCTOR 5. PLEASE COMPLETE ALL THE TESTS REQUIRED IN THIS FORM. 6. PROSPECTIVE CANDIDATES ARE STRONGLY ADVISED TO UNDERGO VACCINATION FOR HEPATITIS B BEFORE JOINING UNIVERSITY PUTRA MALAYSIA. 7. PLEASE ATTACH ALL THE ORIGINAL LABORATORY RESULTS AND THE RESULTS MUST BE REPORTED IN ENGLISH. 8. THE UNVERSITY / COLLEGE ONLY ACCEPTS MEDICAL EXAMINATION DONE WITHIN 60 DAYS BEFORE REGISTRATION OR WITHIN 30 DAYS AFTER REGISTRATION. 9. PLEASE BRING ALONG THE CHEST X-RAY FILM AND REPORT. a PLEASE ENSURE THE X-RAY FILM IS LABELLED WITH YOUR NAME AND DATE TAKEN (IN ENGLISH) b CHEST X-RAY MUST BE DONE WITHIN 6 MONTHS PRIOR TO REGISTRATION 10. 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. 11. 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 APPLICANT HAS GIVEN FALSE INFORMATION IN THE HEALTH EXAMINATION REPORT OR ANY SUPPORTING DOCUMENTS. 12. IT IS STRONGLY RECOMMENDED THAT THIS HEALTH EXAMINATION BE PERFORMED IN MALAYSIA BY MALAYSIAN MEDICAL PRACTITIONERS TO ENSURE COMPLIANCE WITH THE MALAYSIAN MINISTRY OF HEALTH GUIDELINES.
2 Terms and regulation for Health-related Disorder for Admission of International Students by Malaysia s Ministry Of Higher Education. 1. Communicable Disease Type of disease/disorder Example Registration/admission Contagious HIV/AIDS Registration/admission is Recover is expected to be difficult Hepatitis B prohibited and delayed Hepatitis C Contagious Tuberculosis Registration/admission must be Expected to recover with treatment deferred until treatment in home country is completed Deferment should not be for more than two semester Registration requires confirmation from the physician in charge that treatment has been completed Contagious Malaria Registration/admission is allowed Expected to recover with treatment Typhoid only after treatment is completed Syphilis in home country Contagious disease that are Japanese Encephalitis Registration/admission is declared as epidemic by the SARS prohibited Malaysian Ministry of Health Avian flu 2. Non - Communicable Disease Type of disease/disorder Example Registration/admission An attack that may harm the Epilepsy A report is required from the treating student or other Schizophrenia specialist. May be accepted for registration/admission if any of the following is met: Symptom-free for > 12 months Treatment is completed Disease or disorder is expected to End stage renal failure Registration/admission is continue for an unspecified time requiring dialysis prohibited Apparent and serious symptoms Cancer Long treatment schedule Addiction that is direct violation of Drugs Registration/admission is the Malaysian laws Morphine prohibited Canabis Ampethamine Metampethamine Requires continuous medication Hypertension May register if treatment does not No serious symptoms Diabetes Mellitus affect study Treatment not affecting study 1
3 UNIVERSITI PUTRA MALAYSIA HEALTH EXAMINATION REPORT 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 AGE SEX MARITAL STATUS MALE SINGLE D D M M Y Y FEMALE MARRIED ACADEMIC YEAR COURSE CODE SEMESTER / FACULTY MATRIC NO. NEXT OF KIN NEXT OF KIN S ADDRESS NEXT OF KIN S CONTACT NUMBER. RELATIONSHIP. 2
4 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 *IMMEDIATE SELF MEDICAL PROBLEMS FAMILY If Yes please state. Yes No Yes No 1. AIDS, HIV 2. Hepatitis B/C 3. Tuberculosis 4. Drug addiction 5. Congenital or inherited disorder 6. Allergy 7. Mental illness 8. Fits, stroke, other neurological disease 9. Diabetes Mellitus 10. Hypertension 11. Heart or vascular disease 12. Asthma 13. Thyroid disease 14. Kidney disease 15. Cancer 16. History of surgery 17. Other illnesses Current medication (Long term) IMMUNIZATION HISTORY 1. Yellow fever 2. BCG 3. Typhoid 4. Meningitis (Quadrivalent) 5. Hepatitis B 6. Others DATE IMMUNIZED 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 VISION TEST : Unaided : (R) (L) COLOUR BLIND 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 funduscopy) 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 4
6 SECTION 3 - INVESTIGATIONS URINE TEST ITEM DATE TAKEN RESULT a. ALBUMIN b. SUGAR c. MICROSCOPIC d. MORPHINE e. CANNABIS f. AMPHETAMINES g. METHAMPHETAMINES BLOOD TEST ITEM DATE TAKEN RESULT a. HEPATITIS B ANTIGEN b. HEPATITIS B ANTIBODY c. HEPATITIS C d. HIV e. VDRL / TPHA f. MALARIAL PARASITE CHEST X-RAY INFORMATION CHEST X-RAY NO. DATE TAKEN PLACE TAKEN REPORT 5
7 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 FOUND TO HAVE (Please State) HAS MEDICAL PROBLEM (Please State) IS UNDERGOING TREATMENT FOR: (Please State) Date Signature of Doctor : Name of Doctor : Qualification and : Official stamp of Clinic Remarks By University Official : 6
8 FOR VISA APPLICATION Borang RME / IPT International 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 FOUND TO HAVE (Please State) HAS MEDICAL PROBLEM (Please State) IS UNDERGOING TREATMENT FOR: (Please State) Date Signature of Doctor : Name of Doctor : Qualification and : Official stamp of Clinic Remarks By University Official : 7
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New Patient Questionnaire Please complete this and bring it with you to your visit. If you have it completed five days or more prior to your visit, please mail or fax it to our office. Most recent treating
PATIENT REGISTRATION FORM. Last Name: First Name: Initial: Address: City: State: Zip Code: Date of Birth: / / Social: - - address:
TIMOTHY B. COLE, MD ALLISON TRAVIS, MD 7300 Eldorado Parkway, Ste 260, McKinney, TX 75070 Phone: 972-747-0440 / Fax: 972-747-0441 PATIENT REGISTRATION FORM Date: Last Name: First Name: Initial: Address:
Date of Birth: Age: Sex: male female. Weight: Height: Address: Parents: Mother s Phone: (home) (cell) (work) Mother s
*All information provided is kept in strict confidence Child s Name: Date: Date of Birth: Age: Sex: male female Weight: Height: Girls: Age at first period: Address: Parents: Mother s Phone: (home) (cell)
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
MEDICAL QUESTIONNAIRE (female)
MEDICAL QUESTIONNAIRE (female) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501 The appointment comprises of a discussion about this questionnaire and a subsequent medical examination.
Certificate of Health Examination and Immunity
AURORA UNIVERSITY and GEORGE WILLIAMS COLLEGE of AURORA UNIVERSITY School of Nursing Certificate of Health Examination and Immunity Student to complete pages 1-3 Name: Date of Birth: / / Sex: M F SS#:
SAMPLE OF PRE-COURSE OCCUPATIONAL HEALTH QUESTIONNAIRE 2017
SAMPLE OF PRE-COURSE OCCUPATIONAL HEALTH QUESTIONNAIRE 2017 PLEASE NOTE THIS IS FOR GUIDANCE ONLY AND IS SUBJECT TO CHANGE PART A Applicant Personal Information PART B Applicant General Health Information
PATIENT INFORMATION. First
GUIDE DOGS OF AMERICA General Physician s Report This General Physician s Report is being requested in connection with an application for a guide dog. We require a recent physical exam and complete medical
Program or Major Code: Current address: Blazer ID: Local Address: Permanent Address
UAB Student Health and Wellness Health History Form Learning Resource Center 1714 9 th Avenue South, 3 rd Floor Birmingham, Alabama 35294-1270 (205) 934-3580 Please save this form and upload it to CertifiedProfile.com.
Rutgers School of Nursing Center for Professional Development 65 Bergen Street, Room Newark, New Jersey 07107
p 973-972-6655 f 973-972-7904 Dear Participant, The attached health documentation is required for participation in the RN Skills Refresher course per University Policy and is for your protection as well
N E W Y O R K M E D I C A L C O L L E G E A M E M B E R O F T H E T O U R O C O L L E G E A N D U N I V E R I S T Y S Y S T E M
N E W Y O R K M E D I C A L C O L L E G E A M E M B E R O F T H E T O U R O C O L L E G E A N D U N I V E R I S T Y S Y S T E M HEALTH SERVICES BASIC SCIENCES BUILDING VALHALLA, NEW YORK 10595 TEL 914-594-4234
2017/2018 MEDICAL FORM (For Season Ending June 2018)
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SHENANDOAH UNIVERSITY HEALTH FORM
SHENANDOAH UNIVERSITY HEALTH FORM Welcome to Shenandoah University. This cover letter is to help clarify the immunization and testing requirements for our Health Professions Programs. All students admitted
NOTICE TO OUR PATIENTS
SMG Chestnut Street, SMG Elm Street, SMG Mancos Valley, Southwest Walk-In Care, Southwest School-Based Health Center, SMG Market Street, SMG Orthopedics, SMG Pulmonary and Sleep Medicine, SMG General Surgery,