GUIDELINES TO FILL IN HEALTH EXAMINATION REPORT

Similar documents
HEALTH EXAMINATION GUIDELINES

HEALTH EXAMINATION GUIDELINES

HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS

HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS

HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS

Health Examination Guidelines For Entry Into Universiti Tunku Abdul Rahman

HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS

HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS

HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS

PUSAT KESIHATAN UNIVERSITI Universiti Malaysia Perlis, Kampus Pauh Putra, Arau, Perlis, Malaysia. Tel : Fax :

Part 1 : Personal Information (This part is to be completed by the applicant)

UNIVERSITI MALAYSIA SABAH LAPORAN PEMERIKSAAN PERUBATAN MEDICAL EXAMINATION REPORT

UNIVERSITI MALAYA LAPORAN PEMERIKSAAN PERUBATAN MEDICAL EXAMINATION REPORT

MEDICAL EXAMINATION REPORT

Penn State New Kensington Radiological Sciences Program Physical Examination

International School Bangkok Physical Examination Report (New Student)

Student Full Name: Date of Birth:

The North of England P&I Association. The Quayside, Newcastle upon Tyne, NE1 3DU, UK Telephone:

PRE-ADMISSION MEDICAL EXAMINATION FORM (HIGHER NITEC IN EARLY CHILDHOOD EDUCATION) (SERVICE CODE FOR SATA: ITE-HS/EC/SS)

OPTIMA COLLEGE CONTACT CENTRE SUPPORT APPLICATION FORM

PROCLAMATIONS, RULES AND REGULATIONS MARITIME AUTHORITY OF JAMAICA

Ophthalmologist/Optometrist/Low Vision Clinic Report. 1.1 Title: (Mr/Mrs/Miss, etc) Surname: Full Names:. 1.4 Physical Address:.

Instructions for Attorneys on completing the Patient Questionnaire

OCCUPATIONAL HEALTH PROTOCOL

Member's Name RECOMMENDATION

Health screening questionnaire

Medical Examination Form Seafarers

Name: New York Medical College A MEMBER OF THE TOURO COLLEGE AND UNIVERSITY SYSTEM. HEALTH SERVICES HISTORY and PHYSICAL

Notification of Alternative Means of Compliance

Vassar College 124 Raymond Avenue Box 17 Poughkeepsie New York Please contact us at for any questions/concerns.

OCCUPATIONAL HEALTH PROTOCOL

Dear Incoming Student:

Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?

Did you complete the Sports Ware Online required information (

PLEASE PRINT PLEASE CHECK THE BOX AFTER THE PHONE NUMBER THAT YOU WANT AS YOUR PREFERRED NUMBER

Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.

Blue Precision HMO Annual Health Assessment Form - Adult

THIS FORM IS TO BE COMPLETED BY CANDIDATE.

MEDICAL QUESTIONNAIRE (male)

Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:

PATIENT INFORMATION. First

Special Category Volunteer Medical Packet

Shallotte Vision Care J. Mark Saunders, OD PA 4637 Main Street Shallotte NC Patient Demographic Information

The District Medical Officer/ Chairman Medical Board,

St Andrew s College Medical Questionnaire.

Mount Mystics MSVU Athletics & Recreation

Department of State Academic Exchanges Participant Medical History and Examination Form

PATIENT REGISTRATION FORM. Last Name: First Name: Initial: Address: City: State: Zip Code: Date of Birth: / / Social: - - address:

NEUROLOGICAL SURGERY, P.C.

Name of Recipient: Recipient s DOB (if known) Relationship to Recipient: (Example: mother, father, sister, brother, friend, etc)

GASTROCARE, P.C. Contact Preference: HOME: Cell #: Office #: REASON FOR VISIT: Allergies: Current Medications (Name/Dose/How taken):

MEDICAL QUESTIONNAIRE (female)

MEDICAL HISTORY AND EXAMINATION FORM INSTRUCTIONS

EL CENTRO COLLEGE CENTER FOR ALLIED HEALTH AND NURSING HEALTH OCCUPATIONS ADMISSIONS

PERSONAL HEALTH STATEMENT

Attending Physician Statement - Severe asthma

John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter

PATIENT INFORMATION FORM (WOMEN ONLY)

Notto Chiropractic Health Center Patient Information

MODEL FORM MEDICAL REPORT ON THE CHILD. For Contracting States within the scope of the Hague Convention on intercountry adoption

PRE-EMPLOYMENT PHYSICAL - INALFA

It is simply an acronym (short-form) of Gulf Cooperation Council. Members of the Gulf Cooperation Council are ;

2017/2018 MEDICAL FORM (For Season Ending June 2018)

Admission Medical Information Form

REDDY & ASSOCIATES LLC D/B/A Reddy Medical Group D/B/A Reddy Urgent Care. Reddy Urgent Care Pre-Employment Physical Form

APPLICATION PACK CHECKLIST

Medical History Form

PATIENT INFORMATION Please print clearly and complete all blanks

Arcana Center for Integrative Medicine

Sample Process Flow and Quality Assurance Checklist for Immigration Physicals

MEDICAL DATA SHEET For Patients 18 years of age and older

Admission In Basic Fire Fighting Training Course at Airports Authority of India Fire Training Establishment (Delhi & Kolkata) Eligibility Criteria

NEW PATIENT INFORMATION RECORD PATIENT INFORMATION

TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM

Inflammatory Bowel Disease Medical Exam Questionnaire

City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,

NEW PATIENT INFORMATION *All information provided is kept in strict confidence

WELLNESS CENTER Student Health Services (434) FAX (434)

PATIENT REGISTRATION

GoPrivateMD General Information & History

Illinois State University. Athletic Training Education Program

Patient Interview Form

Keiser University Health Forms. Student Name: D.O.B. / /

Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS

PULMONARY MEDICINE PATIENT QUESTIONNAIRE

Retinal Consultants of San Antonio PATIENT REGISTRATION

Occupation Agency Code Work Location Work Supervisor Duty tel. #

Student Health Record

ATTENDING PHYSICIAN'S STATEMENT KIDNEY FAILURE / SURGICAL REMOVAL OF ONE KIDNEY OR CHRONIC KIDNEY DISEASE

PATIENT INTAKE AND HISTORY FORM

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

Patient Interview Form

All Other Medications, Dose Times per day Reason for taking the medication. Phone #

IN-VITRO FERTILIZATION WITH DONATED OOCYTES COMPREHENSIVE HISTORY OF RECIPIENT COUPLE (HUSBAND)

MISSOURI SPINE INSTITUTE John D. Spears, D.O.

DNA CENTER New Patient Information

Chiropractic Case History/Patient Information

Transcription:

GUIDELINES TO FILL IN HEALTH EXAMINATION REPORT 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. PLEASE ATTACH ALL THE ORIGINAL LABORATORY RESULTS AND THE RESULTS MUST BE REPORTED IN ENGLISH. IT MUST BE DONE WITHIN 2 MONTHS PRIOR TO REGISTRATION 7. 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 8. UNIVERSITY HEALTH CENTRE CONCERNED HAS THE RIGHT TO REPEAT THE MEDICAL CHECK-UP SHOULD THERE BE ANY DOUBT OF THE MEDICAL REPORT. ALL COSTS INVOLVED WILL BE PAID BY THE CANDIDATES. 9. 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 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 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 Apparent and serious symptoms Cancer Long treatment schedule Addiction that is direct violation of Drugs Registration/admission is the Malaysian laws Morphine 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) IDENTIFICATION NO(I/C) RACE 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) 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

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

SECTION 3 - INVESTIGATIONS URINE TEST ITEM DATE TAKEN RESULT URINE FEME 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

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback