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 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 / As 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 / PASPORT / IDENTITY CARD / PASSPORT NO. 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
BAHAGIAN 2 Sila tandakan ( / ) di kotak berkenaan PART 2 Please tick ( / ) the relevant box Adakah anda / keluarga mengalami : Lelah, batuk kering, darah tinggi, sakit jantung, kencing manis, sakit buah pinggang, gila babi, sakit jiwa, penyalahgunaan dadah, kecacatan anggota, kanser, alahan, pembedahan. Have you / family has the following: Asthma, tuberculosis, Hypertension, Heart Diseases, Diabetes Mellitus, Kidney Disease, Epilepsy, Mental Illness, Drug Addiction, Deformity, Cancer, Allergic, Operations. Tidak / No Ya / Yes Sendiri / Self Keluarga / Family Jika Ya, sila nyatakan / If Yes, please state: Saya dengan ini mengaku segala maklumat kesihatan yang diberi di atas adalah benar. (I hereby certify that the information given above is true) (..) Tandatangan / Signature of candidate BAHAGIAN 3 UNTUK DIISI OLEH DOKTOR YANG MEMERIKSA Tandakan yang berkaitan / Part 3 TO BE FILLED BY EXAMINING DOCTOR Tick as relevant 1. PEMERIKSAAN UMUM / GENERAL EXAMINATIONS TINGGI / HEIGHT sm/cm BERAT/WEIGHT kilogram NADI / PULSE seminit / per minute BP / mmhg a. PALLOR b. CYANOSIS c. OEDEMO d. JAUNDICE e. LYMPH NODES f. SKIN 2
2. PEMERIKSAAN MATA / KANAN/ KIRI / EXAMINATION OF EYE RIGHT LEFT CATATAN / 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 / HEART NORMAL 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 / DATE OF X-RAY / TAKEN TEMPAT DIAMBIL / PLACE TAKEN NO. RUJUKAN X-RAY / X-RAY REF. NO. D D M M Y Y 7. ABDOMEN & RONGGA HERNIA / NORMAL ABDOMEN & HERNIAL ORIFICES 8. SISTEM SARAF DAN MENTAL / NORMAL NERVOUS SYSTEM AND MENTAL CONDITION 9. SISTEM MUSKULOSKELETAL / NORMAL MUSCULOSKELETAL SYSTEM 10. LAIN-LAIN / OTHERS BAHAGIAN 4 PART 4 11. PEMERIKSAAN AIR KENCING / EXAMINATION OF URINE Gula / Sugar Albumin Microscopy 3
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 No. K/P / I/C 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 Tandatangan Doktor : Tarikh / Date : Signature of Doctor Nama Doktor : Name of Doctor Kelulusan dan Cop Rasmi Klinik : Qualification /Official stamp of hospital / clinic 4
PERAKUAN KEBENARAN BIUS DAN PEMBEDAHAN CLINIC AUTHORISATION FOR ANESTHESIA AND SURGICAL PROCEDURE PEGAWAI KESIHATAN/PERUBATAN MEDICAL OFFICER / STUDENT HEALTH PHYSICIAN UNIVERSITI : UNIVERSITI ISLAM ANTARABANGSA MALAYSIA UNIVERSITY : INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA Saya : Bapa/Ibu/Penjaga kepada (nama calon) I Father/Mother/Guardian to the applicant Nombor Kad Pengenalan IC. Number dengan ini memberi kuasa kepada tuan untuk menandatangani kebenaran bagi pihak saya, jika pada pandangan Doktor yang calon ini memerlukan rawatan bius (anaesthesia) atau/ dan pembedahan, sedangkan saya tidak dapat hadir pada masa yang di perlukan. Hereby authorize the medical officer to administer anaesthesia or carry out a surgical procedure on the applicant in my absence in the event of an emergency as confirmed by the attending doctor. Saya tidak akan mengambil sebarang tindakan kepada Universiti jika berlaku sebarang kemungkinan yang timbul daripada prosedur tersebut.. I will observe the University of any claims or responsibilities from any unfavourable consequences which may arise from the said procedure. Nama Bapa/Ibu/Penjaga Name of father/mother/guardian Alamat: Address Yang benar, Yours faithfully Tandatangan Bapa/Ibu/Penjaga Signature of father/mother/guardian Nombor Telefon: Telephone No. Tarikh : Date 5