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.
Students Name:
NRIC No.:
Students Signature:

Received By:
Staffs Name:
Department/Faculty:
Date Received:

Universiti Tunku Abdul Rahman

Form Title: HEALTH EXAMINATION REPORT

Form Number: FM-DACE-014

Rev No. : 0

Effective Date: 01/01/2011

Page No: 1 of 5

PLEASE USE CAPITAL LETTERS

Passport size
photo

SECTION 1 (To be completed by candidate)

(PART A)

FULL NAME: _______________________________

REGISTRATION NO.: ________________

CONTACT NUMBER: ________________________

DATE OF BIRTH: ___________________

MARITAL STATUS: SINGLE* / MARRIED*

GENDER: MALE* / FEMALE*

PROGRAMME OF STUDY: __________________________________________________________

NEXT OF KIN : ____________________________________________________________________
NEXT OF KINS CONTACT NUMBER: _________________________________________________
NEXT OF KINS ADDRESS: _________________________________________________________
________________________________________________________________________________
* Delete whichever not applicable

Universiti Tunku Abdul Rahman

Form Title: HEALTH EXAMINATION REPORT

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
1. Congenital or inherited disorder

SELF
Yes

No

IMMEDIATE
FAMILY*
Yes

If Yes please specify

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

Universiti Tunku Abdul Rahman

Form Title: HEALTH EXAMINATION REPORT

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

BLOOD PRESSURE : ______________

mmHg

WEIGHT : _____________ kg

PULSE RATE : __________________ / min

VISION TEST: Unaided :( R )

Aided

:( R )

( L ) ____

COLOUR VISION TEST (including Colour

Blindness) :

( L ) ____

NORMAL

/ ABNORMAL*

* Additional comment:
_____________________________________

2. GENERAL EXAMINATION
ITEM

YES

NO

COMMENT

a. DEFORMITIES
b. JAUNDICE
c. OEDEMA
d. SKIN DISEASES
3. SYSTEM EXAMINATION
ITEM

NORMAL

ABNORMAL

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

COMMENT

Universiti Tunku Abdul Rahman

Form Title: HEALTH EXAMINATION REPORT

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

Universiti Tunku Abdul Rahman

Form Title: HEALTH EXAMINATION REPORT

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