LAMPIRAN A HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO. MALAYSIAN HIGHER EDUCATIONAL INSITUTIONS. PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE FILLING IN THE FORM. PLEASE FILL IN THE FORM IN ENGLISH LANGUAGE. PLEASE WRITE IN CAPITAL LETTERS. THIS FORM HAS 4 SECTIONS: a) SECTION 1 (PART A AND B ) TO BE FILLED BY THE APPLICANT; AND b) SECTION 2, 3 AND 4 TO BE FILLED BY THE EXAMINING DOCTOR PLEASE COMPLETE THE ENTIRE TEST REQUIRED IN THIS FORM, THE UNIVERSITY / COLLEGE ONLY ACCEPT MEDICAL EXAMINATION DONE WITHIN 90 DAYS BEFORE ARRIVAL IN MALAYSIA. PLEASE ATTACH ALL THE ORIGINAL LABORATORY RESULTS. PLEASE BRING ALONG CHEST X-RAY FILM (OR DIGITAL IMAGES) AND REPORT FOR REGISTRATION, FOR THE PURPOSE OF VERIFICATION, IF NECESSARY. PLEASE ENSURE THE X-RAY FILMS OR DIGITAL IMAGES ARE LABELLED WITH YOUR NAME AND DATE TAKEN (IN ENGLISH), CHEST X-RAY DONE WITHIN 6 MONTHS PRIOR TO REGISTRATION CAN BE ACCEPTED. 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. 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 THE APPLICANT HAS GIVEN FALSE INFORMATION IN THE HEALTH EXAMINATION REPORT OR ANY SUPPORTING DOCUMENTS.NAME OF INSTITUTION Passport HEALTH EXAMINATION REPORT size photo FOR INTERNATIONAL STUDENT PLEASE USE CAPITAL LETTERS SECTION 4 (To be completed by candidate) (PART A) FULL NAME (AS IN PASSPORT) T INTERNATIONAL PASSPORT NO. BLOOD GROUP (RHESUS) teles] [ee] NATIONALITY CONTACT NUMBER (Je ieee aici et see e, J Cai [ae I DATE OF BIRTH AGE SEX MARITAL STATUS eee Tess Vesa) (ee MALE | SINGLE DoW M YY FEMALE MARRIED ACADEMIC YEAR STUDENT ID CLT Terr T PROGRAMME OF STUDY PROGRAMME CODE EL Co ] a NEXT OF KIN Ie a so a ee Paea ff [es [] NEXT OF KIN'S ADDRESS NEXT OF KIN'S CONTACT NUMBER leSECTION 1 (PART B) - Please tick (¥) in the relevant box Declaration of self and family iiness. Explain in full if you or your family has any of the following iliness, * Immediate family refers to father, mother, brothers / sisters. IMMEDIATE FAMILY | If “yes” please state Yes | No | Yes | No SELF MEDICAL PROBLEMS Congenital or inherited Allergy Mental lines Fits, Stroke, Other Neurological Diseases Diabetes Melitus Hypertension Heart Or Vascular Diseases Asthma 9._Thyroid Diseases 10. Kidney Diseases 11, Cancer 12, History Of Surgery 13, Tuberculosis (TB) 14, HIV/AIDS 16. Hepatitis B 16. Sexually Transmitted Diseases 17. Drug Addiction 18. Other linesses isorder ‘Current medication (Long Term)(wh VACCINATION HISTORY applicable) DATE OF VACCINATION Tellow Fave" 2 BCS 3. Meningitis (Quadrvalent) 4 Hepaiitis 8 5. Polio 6. Measles 7. Rubella 8. Others: (specy) “A valid Yellow Fever vaccination certificate is required from all travellers coming from or transited more than 12 hours through countries with risk of Yellow Fever transmission. Al students are required to take vaccines as listed in numbers 2-7 above, The students are required to to bring along the International Certificate of Vaccination or Prophylaxis with them for verification of information, | hereby certify thatthe information given above is true. | understand that my application wil be rejected if there is any false information given, Signature of candidate‘SECTION 2 - PHYSICAL EXAMINATION To be filled by examining doctor 1. BASIC MEASUREMENT HEIGHT m WEIGHT kg BM (kgm?) BLOOD PRESSURE PULSE RATE mmig Fmin VISION TEST : Uns Aided: COLOUR VISION TEST NORMAL / ABNORMAL, 2. GENERAL EXAMINATION Tem YES NO COMMENT DEFORMITIES PALLOR ‘CYANOSIS JAUNDICE, | OEDEMA. ‘SKIN DISEASES 3. SYSTEMIC EXAMINATION ITEM NORMAL, ‘ABNORMAL, COMMENT EYES (including funduscopy) EARS NOSE ‘ORAL CAVITY / THROAT NECK ‘CARDIOVASCULAR RESPIRATORY ‘ABDOMEN INCLUDING HERNIA ORIFICES ‘8 NERVOUS SYSTEM 10. MENTAL STATUS Ti, MUSCULOSKELETAL SYSTEMSECTION 3 - INVESTIGATIONS URINE TEST ITEM DATE TAKEN RESULT ALBUMIN ‘SUGAR MICROSCOPIC ‘OPIATES (INCLUDING CODEIN, MORPHINE, HEROIN) CANNABINOIDS 1. AMPHETAMINE TYPE STIMULANTS (ATS) BLOOD TEST em DATE TAKEN RESULT HEPATITIS Bs ANTIGEN HIV ANTIBODY VORL & TPHAT MALARIAL PARASITES L “TPHA is done if VORL is reactive ‘all tost reculte! reports ie valid for 3 months: CHEST X-RAY INFORMATION. DATE TAKEN CHEST X-RAY NO, X-RAY FACILITY. 10XRAY REPORT 1. Thoracic Cage 2, Healt Shape at Size (CTR > 0.55, and in fallure OR significant cardiomegaly) 2 Lung Fields 4. Mediastinum and Hilar 5. Pleural Hemidiaphragms! Costopherenic Analles 6. Focal Lesion (E.g, Old/New PTB, Tumour) 7. Any Other ‘Abnormalities 8. Impression ABNORMAL NORMAL, a Oo No DETAILS OF ABNORMALITY | u‘SECTION 4 - CERTIFICATION BY THE EXAMINING DOCTOR Please tick (¥) in the appropriate box {certify that I have on this date Me/ Ms Passport No. ‘and found him / her: [] IN GOOD HEALTH HAVING THE FOLLOWING MEDICAL COMPLICATION(S) (Please State) examined U [came] UNDERGOING TREATMENT FOR; (Please State) ‘YES No 1 HIV o o 2. HEPATITIS o o 3 TUBERCULOSIS fl o 4 MALARIA o o 5 TIFOID o o 6 SEXUALLY TRANSMITTED DISEASES o o 7 PSYCHIATRIC DISORDERS o o 8 EPILEPSY oO od OTHERS 9 (Please specify under Comments) o od 2ALSO FIND THAT: POSITIVE NEGATIVE Hisiner urine for amphetamine type stimulants 10 (ATs) (screening test) Oo Oo ‘11. Hisiher urine for opiates (screening test) o o 12 Hither urine for cannabinoids (screening test) EF] o HEREBY THE STUDENT SUITABLE/UNSUITABLE FOR STUDY (COURSE) IN MALAYSIA Date: Signature of Doctor Name of Doctor Qualification Hospital / Clinic Registration Number Official stamp Remarks By University / College Official 2B