Health Examination Guidelines For Entry Into Universiti Tunku Abdul Rahman

Transcription

1 Health Examination Guidelines For Entry Into Universiti Tunku Abdul Rahman 1. Read the instructions carefully before filling in the form. 2. The form has 4 sections: (a) Section 1 (Parts A and B) to be filled by the candidate; and (b) Sections 2, 3 and 4 to be filled by the examining doctor. Please complete all the tests required in this form. 3. The university only accepts medical examination done within 60 days before registration or within 30 days after registration. 4. Attach all original laboratory result. 5. Chest x-ray done within 6 months prior to registration can be accepted. 6. Please keep the chest x-ray film for future verification, if required. 7. The university reserves the right to request 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. 8. Before submission please make a photocopy of the Health Examination Report and all documents pertaining to the Health Examination for your own reference. 9. This page will be returned to you after it has been acknowledged receipt by a staff of the University. Student s Name: NRIC No.: Student s Signature: Received By: Staff s Name: Department/Faculty: Date Received:

2 Form Number: FM-DACE-014 Rev No. : 0 Effective Date: 01/01/2011 Page No: 1 of 5 PLEASE USE CAPITAL LETTERS SECTION 1 (To be completed by candidate) (PART A) Passport size photo FULL NAME: REGISTRATION NO.: CONTACT NUMBER: DATE OF BIRTH: MARITAL STATUS: SINGLE* / MARRIED* GENDER: MALE* / FEMALE* PROGRAMME OF STUDY: NEXT OF KIN : NEXT OF KIN S CONTACT NUMBER: NEXT OF KIN S ADDRESS: * Delete whichever not applicable 1

3 Form Number: FM-DACE-014 Rev No. : 0 Effective Date: 01/01/2011 Page No: 2 of 5 SECTION 1 (PART B) Please tick ( ) in the relevant box Declaration of self and family illness. Explain in full if you or your family have any of the following illnesses * Immediate family refers to father, mother, brothers / sisters MEDICAL PROBLEMS SELF IMMEDIATE FAMILY* If Yes please specify 1. Congenital or inherited disorder Yes No Yes No 2. Allergy 3. Mental illness 4. Fits, stroke, other neurological disease 5. Diabetes 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) (If applicable) 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 2

4 Form Number: FM-DACE-014 Rev No. : 0 Effective Date: 01/01/2011 Page No: 3 of 5 SECTION 2 PHYSICAL EXAMINATION To be filled by examining doctor 1. BASIC MEASUREMENT HEIGHT : m WEIGHT : kg BLOOD PRESSURE : mmhg PULSE RATE : / min VISION TEST: Unaided :( R ) Aided :( R ) ( L ) ( L ) COLOUR VISION TEST (including Colour Blindness) : * Additional comment: NORMAL / ABNORMAL* 2. GENERAL EXAMINATION ITEM YES NO COMMENT a. DEFORMITIES b. JAUNDICE c. OEDEMA d. SKIN DISEASES 3. SYSTEM 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 i. NERVOUS SYSTEM j. MENTAL CONDITION k. MUSCULOSKELETAL SYSTEM 3

5 Form Number: FM-DACE-014 Rev No. : 0 Effective Date: 01/01/2011 Page No: 4 of 5 SECTION 3 - INVESTIGATION URINE TEST ITEM DATE TAKEN RESULT a. ALBUMIN b. SUGAR c. MICROSCOPIC CHEST X-RAY INFORMATION DATE TAKEN PLACE TAKEN REPORT 4

6 Form Number: FM-DACE-014 Rev No. : 0 Effective Date: 01/01/2011 Page No: 5 of 5 SECTION 4 - CERTIFICATION BY THE EXAMINING DOCTOR Please tick () in the appropriate box I certify that I have on this date examined Mr / Ms IC No. and found him / her:- IN GOOD HEALTH AND FREE OF PSYCHOSIS HAVING THE FOLLOWING MEDICAL COMPLICATION (S) (Please specify) UNDERGOING TREATMENT FOR: (Please specify) Date : Signature of Doctor : Name of Doctor : Address of Hospital/Clinic : Official stamp : Remarks by University Official: 5