IHWC-Clinic/V-02/R-00/ED-01112019

GAMBAR
HEALTH EXAMINATION REPORT PASPORT PELAJAR
(for Malaysian Students)
STUDENT’S
(Please complete Part 1 and 2 only. Part 3, 4, 5 is to be filled by the IIUM Medical Officer only) PASSPORT
ARAHAN: SILA ISI DALAM HURUF BESAR PHOTOGRAPH
INSTRUCTION: PLEASE FILL IN CAPITAL LETTERS

BAHAGIAN 1
PART 1

TAHUN AKADEMIK / ACADEMIC YEAR PROGRAM / PROGRAMME SEMESTER

/ /

KULLIYYAH / FACULTY NO. MATRIK / MATRIC NO. UMUR / AGE

Seperti dalam Surat Tawaran/As in the offer letter

NAMA PENUH / FULL NAME

NO. KAD PENGENALAN / IDENTITY CARD NO. TELEFON / CONTACT NO.

KEWARGANEGARAAN / NATIONALITY TARIKH LAHIR / DATE OF BIRTH

D D M M Y Y Y Y
LELAKI / MALE PEREMPUAN / FEMALE BUJANG / SINGLE KAHWIN / MARRIED

NAMA PENJAGA / NAME OF GUARDIAN

ALAMAT PENJAGA / POSTAL ADDRESS OF GUARDIAN

NO. TELEFON RUMAH / HOUSE TELEPHONE NO. NO. TELEFON PEJABAT / OFFICE TELEPHONE NO.

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 NAMA PENUH & NO. MATRIK / FULL NAME & MATRIC NO

BAHAGIAN 2 – Sila tandakan (/) di kotak berkenaan

PART 2 – Please tick (/) the relevant box

Pengakuan mengenai penyakit yang dihadapi sendiri dan ahli keluarga terdekat (ibu, bapa, adik-beradik). Sila jelaskan
dengan lanjut sekiranya anda atau ahli keluarga menghadapi penyakit-penyakit berikut: / Declaration of self and
immediate family (Father, mother, siblings) illness. Explain in full if you or your family has any of the following illnesses.

SELF IMMEDIATE
NO MEDICAL PROBLEMS FAMILY If Yes, please state
(Masalah Kesihatan) Yes No Yes No (Jika Ya, sila nyatakan)
Congenital or Inherited Disorder (Penyakit
1
Sejak Lahir/Penyakit Keturunan)
2 Allergy (Alergi)
3 Mental Illness (Sakit Jiwa)
Fits, Stroke, Other Neurological Disease
4
(Sawan, Strok dan Lain-Lain Penyakit Saraf)
5 Diabetes Mellitus (Kencing Manis)
6 Hypertension (Darah Tinggi)
7 Heart or Vascular Disease (Sakit Jantung)
8 Asthman (Lelah)
9 Thyroid Disease (Sakit Tiroid)
10 Kidney Disease (Sakit Buah Pinggang)
11 Cancer (Kanser)
12 Tuberculosis (Batuk Kering)
13 Drug Addiction (Penyalahgunaan Dadah)
14 AIDS, HIV
15 Epilepsy (Gila Babi)
16 Deformity (Kecacatan)
17 History of Surgery (Sejarah Pembedahan)
18 Other Illnesses (Lain-Lain Penyakit)

Saya dengan ini mengaku segala maklumat kesihatan yang diberi di atas adalah benar. / I hereby certify that the
information given above is true.

………………………………………………………………… ………………………………………………………….

Tandatangan Calon / Signature of Candidate Tarikh / Date

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 NAMA PENUH & NO. MATRIK / FULL NAME & MATRIC NO.

BAHAGIAN 3 – Untuk Diisi Oleh Doktor Yang Memeriksa

PART 3 – To Be Filled By Examining Doctor

Tandakan yang berkaitan / Tick as relevant

1. PEMERIKSAAN UMUM / GENERAL EXAMINATIONS

TINGGI/HEIGHT cm/sm RAT/WEIGHT kilogram

NADI/PULSE seminit/per minute BP / mmHg

a) PALLOR b) CYNOSIS c) OEDEMA

d) JAUNDICE e) LYMPH NODE f) SKIN

2. PEMERIKSAAN MATA / KANAN KIRI CATATAN/

EXAMINATION OF EYE RIGHT LEFT REMARKS
a. PENGLIHATAN TANPA KACA MATA
/ UNAIDED VISION

b. PENGLIHATAN DENGAN KACA MATA/

AIDED VISION

c. FUNDOSCOPY NORMAL
ABNORMAL

d. PENGLIHATAN WARNA/ NORMAL

COLOUR VISION ABNORMAL

3. PEMERIKSAAN TELINGA/ NORMAL

EXAMINATION OF EAR ABNORMAL

4. RUANG MULUT/ NORMAL

ORAL CAVITY ABNORMAL

5. JANTUNG/ NORMAL
HEART ABNORMAL

6. a. SISTEM RESPIRATORI / NORMAL

RESPIRATORY SYSTEM ABNORMAL

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NAMA PENUH & NO. MATRIK / FULL NAME & MATRIC NO.

b.* X-RAY NORMAL

 .LAMPIRKAN X-RAY DADA SERTA LAPORAN (filem besar)/

 PLEASE ATTACH CHEST X-RAY AND REPORT (large film)

TARIKH X-RAY DIAMBIL/ TEMPAT DIAMBIL/ NO. RUJUKAN X-RAY

DATE OF X-RAY TAKEN PLACE TAKEN X-RAY REF. NO.

7. ABDOMEN & RONGGA HERNIA / NORMAL

ABDOMEN & HERNIA ORIFICES ABNORMAL

8. SISTEM SARAF & MENTAL / NORMAL

NERVOUS SYSTEM & MENTAL ABNORMAL
CONDITION

9. SISTEM MUSKULOSKELETAL/ NORMAL

MUSCULOSKELETAL SYSTEM ABNORMAL

10. LAIN-LAIN / OTHERS

BAHAGIAN 4 / PART4

11. PEMERIKSAAN AIR KENCING / EXAMINATION OF URINE

Gula / Sugar Albumin Microscopy

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NAMA PENUH & NO. MATRIK / FULL NAME & MATRIC NO.

BAHAGIAN 5 / PART 5

MENTAL HEALTH ASSESSMENT BY GENERAL PRACTITIONER

General
A. Neat & Tidy Untidy
Apprearance

Coherent Yes No
B. Speech Quality
Relevant Yes No

Depressed* Yes No

C. Mood Anxious Yes No

Irritable Yes No

D. Affect Appropiate Inappropiate

Thought

E. Delusion Yes No

Suicidality* Yes No

Perception
F.
Hallucination Yes No

Orientation

Time Yes No
G.
Place Yes No

Person Yes No

*Note: Refer to Questionnaire - If ‘Yes’ for any of item C, E, F, or G, to certify as UNSUITABLE.

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NAMA PENUH & NO. MATRIK / FULL NAME & MATRIC NO.

QUESTIONNAIRE

PART A : MOOD YES NO

During the past month, have you been

A. feeling down/depressed for most of the
days?

During the past month, have you lost

B. interest in doing things that you like for most
of the days?

If 'Yes' to question 1 or 2, to tick 'Yes' at DEPRESSED in assessement box.

PART B : SUICIDALITY YES NO

A. Do you feel life is not worth living?

Do you have any thoughts about ending your

B.
life?

If 'Yes' to question 3 or , to tick 'Yes' at SUICIDALITY in assessement box.

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BAHAGIAN 6 / PART 6

PENGESAHAN DOKTOR / Certification by Doctor

Sila tandakan (/) di dalam kotak yang berkenaan / Please tick (/) in the appropriate box

Saya mengesahkan bahawa hari ini saya telah memeriksa/ I certify that on this day i have examined

______________________________________________ No. K/P / I/C _________________________________

dan mendapati bahawa / and found that :-

Beliau tidak menghadapi apa-apa penyakit dan disahkan sihat

The above name is in good health

Beliau mengidap ____________________________

The above named has

Beliau sedang mendapatkan rawatan _______________________

The above named is undergoing treatment

Tandatangan Doktor/Signature of Doctor : ____________________________ Tarikh/Date: ________________

Nama Doktor / Name of Doctor : ______________________________

Kelulusan dan Cop Rasmi Klinik / Qualification and Official Stamp of hospital / clinic:

_______________________________________________