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BORANG LAPORAN KESIHATAN

BORANG LAPORAN KESIHATAN

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Published by: Suriya Mohammad Ghani on Dec 20, 2011
Copyright:Attribution Non-commercial

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12/20/2011

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KEJOHANAN PENCAK SILAT SEKOLAH-SEKOLAH KEMENTERIAN PELAJARANMALAYSIA
MEDICAL REPORTA)PERSONAL PARTICULAR / BUTIRAN PERIBADI
a ] Nama: _______________________________________________ b ]No. K.P: ____________________________________c ] Alamat: _____________________________________________________________________________________________ d ] Sekolah: ______________________________________________e ]Tarikh Lahir : _______________________ f ]Tempat Lahir : ______________________________________________ g ]Jantina: Lelaki / Perempuanh ]Bangsa:Melayu / Cina / India / Lain-laini ]Pernahkah tuan / puan mengidap:i ]Blood in spuntum / Batuk berdarahYa / Tidakii ]Asthma / LelahYa / Tidakiii ]Tuberculosis / Batuk KeringYa / Tidakiv ]Penyakit paru-paru kronikYa / Tidakv ]Hypertension / Darah TinggiYa / Tidakvi ]Heart disease / Penyakit jantungYa / Tidakvii ] Nervous illness / Sakit sarafYa / Tidakviii]Epilepsy / SawanYa / Tidakix ]Lain-lain penyakit _____________________________________________________ _____________________________________________________ Saya mengaku bahawa segala keterangan yang diberikan adalah benar.Tarikh : ________________ Tandatangan : ___________________________ (Nama: )
BORANG LAPORAN PEMERIKSAAN KESIHATAN

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