HEALTH EXAMINATION GUIDELINES

Similar documents
HEALTH EXAMINATION GUIDELINES

GUIDELINES TO FILL IN HEALTH EXAMINATION REPORT

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 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

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

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

MEDICAL EXAMINATION REPORT

PROCLAMATIONS, RULES AND REGULATIONS MARITIME AUTHORITY OF JAMAICA

International School Bangkok Physical Examination Report (New Student)

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

Student Full Name: Date of Birth:

OCCUPATIONAL HEALTH PROTOCOL

Member's Name RECOMMENDATION

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

OCCUPATIONAL HEALTH PROTOCOL

Penn State New Kensington Radiological Sciences Program Physical Examination

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

OPTIMA COLLEGE CONTACT CENTRE SUPPORT APPLICATION FORM

Instructions for Attorneys on completing the Patient Questionnaire

Special Category Volunteer Medical Packet

Dear Incoming Student:

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

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

Did you complete the Sports Ware Online required information (

MEDICAL HISTORY AND EXAMINATION FORM INSTRUCTIONS

Notification of Alternative Means of Compliance

Department of State Academic Exchanges Participant Medical History and Examination Form

Admission Medical Information Form

Student Health Center Phone: Fax:

PATIENT INFORMATION FORM (WOMEN ONLY)

Medical Examination Form Seafarers

Health screening questionnaire

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

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

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

Blue Precision HMO Annual Health Assessment Form - Adult

Illinois State University. Athletic Training Education Program

PRE-EMPLOYMENT PHYSICAL - INALFA

Student Health Record

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

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

The District Medical Officer/ Chairman Medical Board,

Juntendo University Hospital Immunization Requirements

APPLICATION PACK CHECKLIST

THIS FORM IS TO BE COMPLETED BY CANDIDATE.

Part I: Health Form. This form is to be completed by the incoming student by July 15. Name: Date of Birth:

Student Health Information

Occupation Agency Code Work Location Work Supervisor Duty tel. #

Student Health Record

THE KEATS GROUP PRACTICE REGISTRATION FORM PLEASE COMPLETE IN BLOCK CAPITALS PERSONAL BACKGROUND INFORMATION

Signature of student Date Signature of parent or guardian (if student is a minor) Date

St Andrew s College Medical Questionnaire.

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

Instructions: Please bring these forms to your Physical Examination & TB Test and have the Doctor fill them out. (Where applicable)

Home Number: ( ) Cell Number: ( ) SSN#: Address: Address: Date of Birth Sex. Place of Birth Marital Status: (Optional) (City & State)

Name Age Birthday / / Sex Last First MI. Home Address Street Apt City State Zip Code Home phone: ( ) Cell phone: ( ) Name of parent(s) or guardian:

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

MEDICAL QUESTIONNAIRE (male)

GoPrivateMD General Information & History

Attending Physician Statement - Severe asthma

Retinal Consultants of San Antonio PATIENT REGISTRATION

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

Following this letter are health forms for parents or legal guardians to complete and sign. Please note that:

99 SOUTH ALCANIZ STREET SUITE B PENSACOLA, FL

Immunization Packet for Incoming Students

Notto Chiropractic Health Center Patient Information

Sample Process Flow and Quality Assurance Checklist for Immigration Physicals

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

P L E A S E N O T E - There will be a charge for each person, even if your travel has been discussed previously with your own GP.

STUDENT HEALTH SERVICES IMMUNIZATION FORM FOR GUILFORD COLLEGE 5800 West Friendly Avenue Greensboro, NC 27410

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

How to Submit Your Preregistration Requirements

Mount Mystics MSVU Athletics & Recreation

Arcana Center for Integrative Medicine

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

A. Please include any medications (herbal, prescription, or Over-the-counter) and any supplements that you are currently taking.

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

Date of Birth: Age: Sex: male female. Weight: Height: Address: Parents: Mother s Phone: (home) (cell) (work) Mother s

Medical History Form

MEDICAL QUESTIONNAIRE (female)

Certificate of Health Examination and Immunity

SAMPLE OF PRE-COURSE OCCUPATIONAL HEALTH QUESTIONNAIRE 2017

PATIENT INFORMATION. First

Program or Major Code: Current address: Blazer ID: Local Address: Permanent Address

Rutgers School of Nursing Center for Professional Development 65 Bergen Street, Room Newark, New Jersey 07107

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

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

SHENANDOAH UNIVERSITY HEALTH FORM

NOTICE TO OUR PATIENTS

Transcription:

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 UNIVERSITY PUTRA MALAYSIA. 7. PLEASE ATTACH ALL THE ORIGINAL LABORATORY RESULTS AND THE RESULTS MUST BE REPORTED IN ENGLISH. 8. THE UNVERSITY / COLLEGE ONLY ACCEPTS MEDICAL EXAMINATION DONE WITHIN 60 DAYS BEFORE REGISTRATION OR WITHIN 30 DAYS AFTER REGISTRATION. 9. 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 10. THE UNIVERSITY / COLLEGE RESERVES 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. 11. 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. 12. IT IS STRONGLY RECOMMENDED THAT THIS HEALTH EXAMINATION BE PERFORMED IN MALAYSIA BY MALAYSIAN MEDICAL PRACTITIONERS TO ENSURE COMPLIANCE WITH THE MALAYSIAN MINISTRY OF HEALTH GUIDELINES.

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. 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 a. ALBUMIN b. SUGAR c. MICROSCOPIC d. MORPHINE e. CANNABIS f. AMPHETAMINES g. METHAMPHETAMINES 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 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

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