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 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 ALL HE TESTS REQUIRED IN THIS FORM 6. THE UNIVERSITY / COLLEGE ONLY ACCEPT MEDICAL EXAMINATION DONE WITHIN 60 DAYS BEFORE REGISTRATION OR WITHIN 30 DAYS AFTER REGISTRATION. 7. PLEASE ATTACH ALL THE ORIGINAL LABORATORY RESULTS. 8. PLEASE BRING ALONG CHEST X-RAYS FILM AND REPORT FOR REGISTRATION. 9. PLEASE ENSURE THE X-RAY FILM IS LABELLED WITH YOUR NAME AND DATE TAKEN (IN ENGLISH) 10. CHESE X-RAY DONE WITHIN 6 MONTHS PRIOR TO REGISTRATION CAN BE ACCEPTED. 11. THE UNIVERSITY / COLLEGE RESERVE 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. 1
2 UNIVERSITI SAINS MALAYSIA HEALTH EXAMINATION REPORT FOR INTERNATIONAL STUDENT AND ACCOMPANYING PERSON SECTION 1 (To be completed by candidate) (PART A) PLEASE USE CAPITAL LETTERS Passport size photo with blue background (3.5 cm x 5.0 cm) 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 / STUDENT ID PROGRAMME OF STUDY PROGRAMME CODE NEXT OF KIN NEXT OF KIN S ADDRESS NEXT OF KIN S CONTACT NUMBER 2
3 SECTION 1 (PART B) Please tick ( ) in the relevant box Declaration of self and/or 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 SELF IMMEDIATE FAMILY Yes No Yes No 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 disease 10. Kidney disease 11. Cancer 12. Tuberculosis 13. Drug addiction 14. AIDS, HIV 15. History of surgery 16. Other illnesses IF YES PLEASE STATE Current Medication (Long term) IMMUNIZATION HISTORY DATE IMMUNIZED (where applicable) 1. Yellow Fever 2. BCG 3. Meningitis (Quadrivalent) 4. Hepatitis B 5. 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 Signature of candidate 3
4 SECTION 2 PHYSICAL EXAMINATION To be filled by examining doctor 1. BASIC MEASUREMENT HEIGHT : BLOOD PRESSURE : WEIGHT : PULSE RATE : 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. SYSTEM EXAMINATION ITEM 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 NORMAL ABNORMAL COMMENT 4
5 SECTION 3 INVESTIGATIONS URINE TEST ITEM DATE TAKEN RESULT a. ALBUMIN b. SUGAR c. MICROSCOPIC d. MORPHINE e. CANNABIS f. AMPHETAMINES TYPE STIMULANT BLOOD TEST ITEM DATE TAKEN RESULT a. HEPATITIS Bs ANTIGEN b. HEPATITIS C c. HIV d. VDRL / TPHA e. MALARIAL PARASITE CHEST X-RAY INFORMATION CHEST X-RAY NO. DATE TAKEN PLACE TAKEN REPORT 5
6 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 : 6
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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NEW PATIENT INFORMATION *All information provided is kept in strict confidence
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Patient Interview Form
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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
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