HEALTH EXAMINATION GUIDELINES

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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 UNIVERSITI PUTRA MALAYSIA. 7. PLEASE TAKE NOTE THAT IT IS COMPULSORY FOR ALL INTERNATIONAL STUDENTS TO DO THEIR MEDICAL CHECK UP FOR UPM STUDENT PASS AT UPM UNIVERSITY HEALTH CENTRE / PUSAT KESIHATAN UNIVERSITI UPM. 8. 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.

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

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

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. *Those who have the listed medical problems above(in 1,2,3 or 4),please kindly DO NOT proceed with your application. Date Signature of candidate 3

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 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

SECTION 3 - INVESTIGATIONS (must be written in English Language) URINE TEST ITEM DATE TAKEN RESULT a. ALBUMIN b. SUGAR c. MICROSCOPIC d. MORPHINE e. CANNABIS f. AMPHETAMINES g. METHAMPHETAMINES (must be written in English Language) 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 (must be written in English Language) CHEST X-RAY INFORMATION CHEST X-RAY NO. DATE TAKEN PLACE TAKEN REPORT 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 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

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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