LAPORAN PEMERIKSAAN KESIHATAN

REPORT OF HEALTH EXAMINATION

SILA ISI DALAM HURUF BESAR
PLEASE FILL IN CAPITALS
Untuk diisi oleh clon
To be completed by the candidate
BAHA!IAN "
Part 1
TAHUN AKADEMIK/ACADEMIC YEAR KOD KURSUS SEMESTER


Se#e$ti dl% su$t t&$n/As in offer letter
FAKULTI'PUSAT'FACULTY NO(PENDAFTARAN/MATRIC (RE! "#$

NAMA PENUH/FULL NAME
NO( KAD PEN!ENALAN 'PASSPORT/IDENTITY CARD/PASSPORT NO. UMUR / AGE

KE)AR!ANE!ARAAN / NATIONALITY TARIKH LAHIR / DATE OF BIRT
LELAKI / MALE PEREMPUAN / FEMALE BU*AN!/ SINGLE KAH)IN / MARRIED
NAMA PEN*A!A / NAME OF GUARDIAN
ALAMAT PEN*A!A / POSTAL ADDRESS OF GUARDIAN
NO( TELEFON RUMAH / OUSE TELEPONE NO. NO( TELEFON PE*ABAT/ OFFICE TELEPONE
BAHA!IAN + , Sil tndkn -./ di kotk 0e$kenn(
PART % & Plea'e tic( ()$ the rele*ant bo+!
Tidk/"o 1/Ye'
Adkh nd'kelu$2 nd %en2l%i 3 Lelh4 0tuk ke$in24 d$h tin22i4 skit 5ntun24 Sendi$i',el-
kencin2 %nis4 skit 0uh #in22n24 2il 00i4 skit 5i&4 #en6lh2unn ddh4 Kelu$2'Family
kecctn n22ot4 knse$4 lhn4 #e%0edhn(
.a*e yo/0yo/r -amily had the -ollo1in2 3 A'thma4 t/berc/lo'i'4 hyperten'ion4 heart di'ea'e'4
diabete' mellit/'4 (idney di'ea'e4 epilep'y4 mental illne''4 dr/2 addiction4 de-ormity4 cancer4
aller2ie'4 operation'!
*ik 14 sil n6tkn / I- ye'4 plea'e 'tate !!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!
S6 den2n ini %en2ku se2l %klu%t kesihtn 6n2 di0e$i di ts dlh 0en$(
( I hereby certi-y that the in-ormation 2i*en abo*e in correct$
"""""""""" #""""""""""""$
#T$ikh/Date$ Tndtn2n
(,i2nat/re o- Candidate$
BAHA!IAN 7 UNTUK DIISI OLEH DOKTOR 1AN! MEMERIKSA Tndkn 6n2 0e$kitn
PART 5 T# 6E FILLED 6Y E7AMI"I" D#CT#R Tic( a' rele*ant
%. PEMERIKSAAN UMUM / GENERAL E&AMINATIONS
TIN!!I/ BERAT /
.EI.T senti'eter/(' 8EI.T )ilo*r+'
PULSE se'init/'in BP ''*
Tndkn 8'9 6n2 0e$kitn
Tic( 90: a' rele*ant
+. PALLOR ,. CYANOSIS (. OEDEMA -. .AUNDICE
e. ENLARGED LYMPNODES f. CRONIC SKIN DISEASE
/( PEMERIKSAAN MATA / KANAN KIRI Cttn Dokto$/;eri-ication o- doctor<' -indin2'
E7AMI"ATI#" #F EYE
+. PEN!LIHATAN TANPA KACA MATA'
U"AIDED ;I,I#"
,. PEN!LIHATAN DEN!AN KACA MATA '
AIDED ;I,I#"
(. FUNDOSCOP1 NORMAL
ABNORMAL
-( PEN!LIHATAN )ARNA' NORMAL
COLOUR :ISION ABDORMAL
0( PEMERIKSAAN TELIN!A NORMAL
E7AMI"ATI#" #F EAR ABNORMAL
1( RUAN! MULUT ; !I!I NORMAL
#RAL CA;ITY = TEET. ABNORMAL
2( *ANTUN! ' .EART NORMAL
ABNORMAL
PERAKUAN KEBENARAN BIUS -ANAESTHESIA/ DAN PEMBEDAHAN
3
AUTORISATION FOR ANATESIA AND SURGICAL PROCEDURE
Pen-+ft+r / Re*istr+r
Kole4 Uni5ersiti Isl+' M+l+6si+
S+6+ 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No. K+- Pen*en+l+n / P+s8ort !!!!!!!!!!!!!!!! B+8+ / I,9 / Pen4+*+ )e8+-+
I0C 0 Pa''port "o! -ather 0 mother 0 2/ardian to
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No. K+- Pen*en+l+n / P+s8ort !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
#N+'+ (+lon / Candidate<' name$ I/C / Pa''port "o!
-en*+n ini 'e',eri )9+s+ )e8+-+ t9+n 9nt9) 'en+n-+t+n*+ni )e,en+r+n ,+*i 8i:+) s+6+; 4i)+ 8+-+ 8+n-+n*+n -o)tor 6+n* (+lon ini
'e'erl9)+n r+<+t+n ,i9s # +n+est:esi+$ +t+9 / -+n 8e',e-+:+n se*er+; se-+n*)+n s+6+ ti-+) -+8+t :+-ir 8+-+ '+s+ 6+n* -i8erl9)+n.
.ereby a/thori'ed the medical o--icer to 'i2n on my behal- a' an appro*al to admini'ter anae'the'ia or carry o/t a '/r2ical proced/re
on the applicant in my ab'ence in the e*ent o- an emer2ency a' con-irmed by the attendin2 doctor4 1hen re>/ired.
S+6+ ti-+) +)+n 'en*+',il se,+r+n* tin-+)+n ter:+-+8 Kole4 Uni5ersiti Isl+' M+l+6si+ -+n 'e',e,+s)+n Uni5ersiti ini -+ri
se,+r+n* t9nt9t+n s+'+ +-+ -+ri 8i:+) s+6+ +t+9 8i:+) l+in 4i)+ ,erl+)9 se,+r+n* )e'9n*)in+n 6+n* ti',9l -+ri8+-+ 8rose-9r terse,9t.
I 1ill ab'ol*e ?ole@ Uni*er'iti I'lam Malay'ia o- any claim' -rom my'el- or any other partie' -or any /n-a*o/rable con'e>/ence'
1hich may ari'e -rom the 'aid proced/re!
Di :+-+8+n / In the pre'ence o- Y+n* ,en+r;
T+n-+t+n*+n / ,i2nat/re Yo/r' Faith-/lly4
!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!
#N+'+ S+)si / N+'e of =itness $ T+n-+t+n*+n B+8+/I,9/Pen4+*+
,i2nat/re o- -ather0mother02/radian
No. K+- Pen*en+l+n / P+s8ort S+)si 7 !!!!!!!!!!!!!!!!!!!!!!!!!
I0C "o! 0 Pa''port "o! o- 8itne'' 3 T+ri): 7 AAAAAAAAAAAAAAAAAAAAAA
Date
Al+'+t S+)si 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
A--ress of =itness 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Tndkn 6n2 0e$kitn
Tic( a' rele*ant
>. +( SISTEM RESPIRATORI ' NORMAL
RE,PIRAT#RY ,Y,TEM ABNORMAL !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
,. < =9RA1 DADA ' NORMAL
C.E,T 7:RAY ABNORMAL

< LAMPIRKAN =9RA1 DADA SERTA LAPORAN ->ile% 0es$/ / ATTAC. C.E,T 7:RAY A"D REP#RT (lar2e -ilm$
TARIKH =9RA1 ' DATE X-RAY TEMPAT / PLACE NO( RU*UK =9RA1/ 7:RAY REF! "#!

?. ABDOMEN ; RON!!A HERNIA / NORMAL
A6D#ME" = .ER"IAL #RIFFICE, ABNORMAL
@. SISTEM SARAF DAN MENTAL / NORMAL
"ER;#U, ,Y,TEM A"DME"TAL C#"DITI#" ABNORMAL
A. SISTEM MUSKULOSKELETAL / NORMAL
MU,CUL#,?ELETAL ,Y,TEM ABNORMAL
%B. LAIN9LAIN / OTERS !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
BAHA!IAN ?
PART B
%% PEMERIKSAAN AIR KENCIN! / E&AMINATION OF URINE
!ULA ALBUMIN MICROSCOP1 !!!!!!!!!!!!!!!!!!
,UAR
BAHA!IAN @
PART C
PEN!ESAHAN DOKTOR / Certifi(+tion ,6 Do(tor
Sil tndkn . di dl% kotk 6n2 0e$kenn( Plea'e tic( ) in the appropriate bo+!
S6 %en2eshkn 0h& #d h$i ini s6 telh %e%e$iks 0 I certi-y that I ha*e thi' day ea+mined
AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA No( K'P I/C No. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
dn %end#ti 0h& 3
and -o/nd 3
Beliu tidk %en2hid# #9# #en6kit dn dishkn siht(
The abo*e named i' in 2ood health!
Beliu %en2hid# !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
The abo*e named ha'
Beliu sedn2 %end#t $&tn !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
The abo*e named i' /nder2oin2 treatment
Tndtn2n Dokto$ !!!!!!!!!!!!!!!!!!!!!!
,i2nat/re o- Doctor
N% Dokto$ AAAAAAAAAAAAAAAAAAAAAAAAAAA
TARIKH 3 !!!!!!!!!!!!!!!! "ame o- Doctor
DATE 3 Kelulusn dn Co# Rs%i Klinik !!!!!!!!!!!
D/ali-ication and o--icial 'tamp o- clinic
LAPORAN PEMERIKSAAN KESIHATAN
REPORT OF HEALTH EXAMINATION
SILA ISI DALAM HURUF BESAR
PLEASE FILL IN CAPITALS
Untuk diisi oleh clon
To be completed by the candidate
BAHA!IAN "
Part 1
TAHUN AKADEMIK/ACADEMIC YEAR KOD KURSUS SEMESTER


Se#e$ti dl% su$t t&$n/As in offer letter
FAKULTI'PUSAT'FACULTY NO(PENDAFTARAN/MATRIC (RE! "#$

NAMA PENUH/FULL NAME
NO( KAD PEN!ENALAN 'PASSPORT/IDENTITY CARD/PASSPORT NO. UMUR / AGE

KE)AR!ANE!ARAAN / NATIONALITY TARIKH LAHIR / DATE OF BIRT
LELAKI / MALE PEREMPUAN / FEMALE BU*AN!/ SINGLE KAH)IN / MARRIED
NAMA PEN*A!A / NAME OF GUARDIAN
ALAMAT PEN*A!A / POSTAL ADDRESS OF GUARDIAN
NO( TELEFON RUMAH / OUSE TELEPONE NO. NO( TELEFON PE*ABAT/ OFFICE TELEPONE
BAHA!IAN + , Sil tndkn -./ di kotk 0e$kenn(
PART % & Plea'e tic( ()$ the rele*ant bo+!
Tidk/"o 1/Ye'
Adkh nd'kelu$2 nd %en2l%i 3 Lelh4 0tuk ke$in24 d$h tin22i4 skit 5ntun24 Sendi$i',el-
kencin2 %nis4 skit 0uh #in22n24 2il 00i4 skit 5i&4 #en6lh2unn ddh4 Kelu$2'Family
kecctn n22ot4 knse$4 lhn4 #e%0edhn(
.a*e yo/0yo/r -amily had the -ollo1in2 3 A'thma4 t/berc/lo'i'4 hyperten'ion4 heart di'ea'e'4
diabete' mellit/'4 (idney di'ea'e4 epilep'y4 mental illne''4 dr/2 addiction4 de-ormity4 cancer4
aller2ie'4 operation'!
*ik 14 sil n6tkn / I- ye'4 plea'e 'tate !!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!
S6 den2n ini %en2ku se2l %klu%t kesihtn 6n2 di0e$i di ts dlh 0en$(
( I hereby certi-y that the in-ormation 2i*en abo*e in correct$
"""""""""" #""""""""""""$
#T$ikh/Date$ Tndtn2n
(,i2nat/re o- Candidate$
BAHA!IAN 7 UNTUK DIISI OLEH DOKTOR 1AN! MEMERIKSA Tndkn 6n2 0e$kitn
PART 5 T# 6E FILLED 6Y E7AMI"I" D#CT#R Tic( a' rele*ant
%. PEMERIKSAAN UMUM / GENERAL E&AMINATIONS
TIN!!I/ BERAT /
.EI.T senti'eter/(' 8EI.T )ilo*r+'
PULSE se'init/'in BP ''*
Tndkn 8'9 6n2 0e$kitn
Tic( 90: a' rele*ant
+. PALLOR ,. CYANOSIS (. OEDEMA -. .AUNDICE
e. ENLARGED LYMPNODES f. CRONIC SKIN DISEASE
/( PEMERIKSAAN MATA / KANAN KIRI Cttn Dokto$/;eri-ication o- doctor<' -indin2'
E7AMI"ATI#" #F EYE
+. PEN!LIHATAN TANPA KACA MATA'
U"AIDED ;I,I#"
,. PEN!LIHATAN DEN!AN KACA MATA '
AIDED ;I,I#"
(. FUNDOSCOP1 NORMAL
ABNORMAL
-( PEN!LIHATAN )ARNA' NORMAL
COLOUR :ISION ABDORMAL
0( PEMERIKSAAN TELIN!A NORMAL
E7AMI"ATI#" #F EAR ABNORMAL
1( RUAN! MULUT ; !I!I NORMAL
#RAL CA;ITY = TEET. ABNORMAL
2( *ANTUN! ' .EART NORMAL
ABNORMAL
PERAKUAN KEBENARAN BIUS -ANAESTHESIA/ DAN PEMBEDAHAN
3
AUTORISATION FOR ANATESIA AND SURGICAL PROCEDURE
Pen-+ft+r / Re*istr+r
Kole4 Uni5ersiti Isl+' M+l+6si+
S+6+ 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No. K+- Pen*en+l+n / P+s8ort !!!!!!!!!!!!!!!! B+8+ / I,9 / Pen4+*+ )e8+-+
I0C 0 Pa''port "o! -ather 0 mother 0 2/ardian to
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No. K+- Pen*en+l+n / P+s8ort !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
#N+'+ (+lon / Candidate<' name$ I/C / Pa''port "o!
-en*+n ini 'e',eri )9+s+ )e8+-+ t9+n 9nt9) 'en+n-+t+n*+ni )e,en+r+n ,+*i 8i:+) s+6+; 4i)+ 8+-+ 8+n-+n*+n -o)tor 6+n* (+lon ini
'e'erl9)+n r+<+t+n ,i9s # +n+est:esi+$ +t+9 / -+n 8e',e-+:+n se*er+; se-+n*)+n s+6+ ti-+) -+8+t :+-ir 8+-+ '+s+ 6+n* -i8erl9)+n.
.ereby a/thori'ed the medical o--icer to 'i2n on my behal- a' an appro*al to admini'ter anae'the'ia or carry o/t a '/r2ical proced/re
on the applicant in my ab'ence in the e*ent o- an emer2ency a' con-irmed by the attendin2 doctor4 1hen re>/ired.
S+6+ ti-+) +)+n 'en*+',il se,+r+n* tin-+)+n ter:+-+8 Kole4 Uni5ersiti Isl+' M+l+6si+ -+n 'e',e,+s)+n Uni5ersiti ini -+ri
se,+r+n* t9nt9t+n s+'+ +-+ -+ri 8i:+) s+6+ +t+9 8i:+) l+in 4i)+ ,erl+)9 se,+r+n* )e'9n*)in+n 6+n* ti',9l -+ri8+-+ 8rose-9r terse,9t.
I 1ill ab'ol*e ?ole@ Uni*er'iti I'lam Malay'ia o- any claim' -rom my'el- or any other partie' -or any /n-a*o/rable con'e>/ence'
1hich may ari'e -rom the 'aid proced/re!
Di :+-+8+n / In the pre'ence o- Y+n* ,en+r;
T+n-+t+n*+n / ,i2nat/re Yo/r' Faith-/lly4
!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!
#N+'+ S+)si / N+'e of =itness $ T+n-+t+n*+n B+8+/I,9/Pen4+*+
,i2nat/re o- -ather0mother02/radian
No. K+- Pen*en+l+n / P+s8ort S+)si 7 !!!!!!!!!!!!!!!!!!!!!!!!!
I0C "o! 0 Pa''port "o! o- 8itne'' 3 T+ri): 7 AAAAAAAAAAAAAAAAAAAAAA
Date
Al+'+t S+)si 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
A--ress of =itness 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Tndkn 6n2 0e$kitn
Tic( a' rele*ant
>. +( SISTEM RESPIRATORI ' NORMAL
RE,PIRAT#RY ,Y,TEM ABNORMAL !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
,. < =9RA1 DADA ' NORMAL
C.E,T 7:RAY ABNORMAL

< LAMPIRKAN =9RA1 DADA SERTA LAPORAN ->ile% 0es$/ / ATTAC. C.E,T 7:RAY A"D REP#RT (lar2e -ilm$
TARIKH =9RA1 ' DATE X-RAY TEMPAT / PLACE NO( RU*UK =9RA1/ 7:RAY REF! "#!

?. ABDOMEN ; RON!!A HERNIA / NORMAL
A6D#ME" = .ER"IAL #RIFFICE, ABNORMAL
@. SISTEM SARAF DAN MENTAL / NORMAL
"ER;#U, ,Y,TEM A"DME"TAL C#"DITI#" ABNORMAL
A. SISTEM MUSKULOSKELETAL / NORMAL
MU,CUL#,?ELETAL ,Y,TEM ABNORMAL
%B. LAIN9LAIN / OTERS !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
BAHA!IAN ?
PART B
%% PEMERIKSAAN AIR KENCIN! / E&AMINATION OF URINE
!ULA ALBUMIN MICROSCOP1 !!!!!!!!!!!!!!!!!!
,UAR
BAHA!IAN @
PART C
PEN!ESAHAN DOKTOR / Certifi(+tion ,6 Do(tor
Sil tndkn . di dl% kotk 6n2 0e$kenn( Plea'e tic( ) in the appropriate bo+!
S6 %en2eshkn 0h& #d h$i ini s6 telh %e%e$iks 0 I certi-y that I ha*e thi' day ea+mined
AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA No( K'P I/C No. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
dn %end#ti 0h& 3
and -o/nd 3
Beliu tidk %en2hid# #9# #en6kit dn dishkn siht(
The abo*e named i' in 2ood health!
Beliu %en2hid# !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
The abo*e named ha'
Beliu sedn2 %end#t $&tn !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
The abo*e named i' /nder2oin2 treatment
Tndtn2n Dokto$ !!!!!!!!!!!!!!!!!!!!!!
,i2nat/re o- Doctor
N% Dokto$ AAAAAAAAAAAAAAAAAAAAAAAAAAA
TARIKH 3 !!!!!!!!!!!!!!!! "ame o- Doctor
DATE 3 Kelulusn dn Co# Rs%i Klinik !!!!!!!!!!!
D/ali-ication and o--icial 'tamp o- clinic
LAPORAN PEMERIKSAAN KESIHATAN
REPORT OF HEALTH EXAMINATION
SILA ISI DALAM HURUF BESAR
PLEASE FILL IN CAPITALS
Untuk diisi oleh clon
To be completed by the candidate
BAHA!IAN "
Part 1
TAHUN AKADEMIK/ACADEMIC YEAR KOD KURSUS SEMESTER


Se#e$ti dl% su$t t&$n/As in offer letter
FAKULTI'PUSAT'FACULTY NO(PENDAFTARAN/MATRIC (RE! "#$

NAMA PENUH/FULL NAME
NO( KAD PEN!ENALAN 'PASSPORT/IDENTITY CARD/PASSPORT NO. UMUR / AGE

KE)AR!ANE!ARAAN / NATIONALITY TARIKH LAHIR / DATE OF BIRT
LELAKI / MALE PEREMPUAN / FEMALE BU*AN!/ SINGLE KAH)IN / MARRIED
NAMA PEN*A!A / NAME OF GUARDIAN
ALAMAT PEN*A!A / POSTAL ADDRESS OF GUARDIAN
NO( TELEFON RUMAH / OUSE TELEPONE NO. NO( TELEFON PE*ABAT/ OFFICE TELEPONE
BAHA!IAN + , Sil tndkn -./ di kotk 0e$kenn(
PART % & Plea'e tic( ()$ the rele*ant bo+!
Tidk/"o 1/Ye'
Adkh nd'kelu$2 nd %en2l%i 3 Lelh4 0tuk ke$in24 d$h tin22i4 skit 5ntun24 Sendi$i',el-
kencin2 %nis4 skit 0uh #in22n24 2il 00i4 skit 5i&4 #en6lh2unn ddh4 Kelu$2'Family
kecctn n22ot4 knse$4 lhn4 #e%0edhn(
.a*e yo/0yo/r -amily had the -ollo1in2 3 A'thma4 t/berc/lo'i'4 hyperten'ion4 heart di'ea'e'4
diabete' mellit/'4 (idney di'ea'e4 epilep'y4 mental illne''4 dr/2 addiction4 de-ormity4 cancer4
aller2ie'4 operation'!
*ik 14 sil n6tkn / I- ye'4 plea'e 'tate !!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!
S6 den2n ini %en2ku se2l %klu%t kesihtn 6n2 di0e$i di ts dlh 0en$(
( I hereby certi-y that the in-ormation 2i*en abo*e in correct$
"""""""""" #""""""""""""$
#T$ikh/Date$ Tndtn2n
(,i2nat/re o- Candidate$
BAHA!IAN 7 UNTUK DIISI OLEH DOKTOR 1AN! MEMERIKSA Tndkn 6n2 0e$kitn
PART 5 T# 6E FILLED 6Y E7AMI"I" D#CT#R Tic( a' rele*ant
%. PEMERIKSAAN UMUM / GENERAL E&AMINATIONS
TIN!!I/ BERAT /
.EI.T senti'eter/(' 8EI.T )ilo*r+'
PULSE se'init/'in BP ''*
Tndkn 8'9 6n2 0e$kitn
Tic( 90: a' rele*ant
+. PALLOR ,. CYANOSIS (. OEDEMA -. .AUNDICE
e. ENLARGED LYMPNODES f. CRONIC SKIN DISEASE
/( PEMERIKSAAN MATA / KANAN KIRI Cttn Dokto$/;eri-ication o- doctor<' -indin2'
E7AMI"ATI#" #F EYE
+. PEN!LIHATAN TANPA KACA MATA'
U"AIDED ;I,I#"
,. PEN!LIHATAN DEN!AN KACA MATA '
AIDED ;I,I#"
(. FUNDOSCOP1 NORMAL
ABNORMAL
-( PEN!LIHATAN )ARNA' NORMAL
COLOUR :ISION ABDORMAL
0( PEMERIKSAAN TELIN!A NORMAL
E7AMI"ATI#" #F EAR ABNORMAL
1( RUAN! MULUT ; !I!I NORMAL
#RAL CA;ITY = TEET. ABNORMAL
2( *ANTUN! ' .EART NORMAL
ABNORMAL
PERAKUAN KEBENARAN BIUS -ANAESTHESIA/ DAN PEMBEDAHAN
3
AUTORISATION FOR ANATESIA AND SURGICAL PROCEDURE
Pen-+ft+r / Re*istr+r
Kole4 Uni5ersiti Isl+' M+l+6si+
S+6+ 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No. K+- Pen*en+l+n / P+s8ort !!!!!!!!!!!!!!!! B+8+ / I,9 / Pen4+*+ )e8+-+
I0C 0 Pa''port "o! -ather 0 mother 0 2/ardian to
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No. K+- Pen*en+l+n / P+s8ort !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
#N+'+ (+lon / Candidate<' name$ I/C / Pa''port "o!
-en*+n ini 'e',eri )9+s+ )e8+-+ t9+n 9nt9) 'en+n-+t+n*+ni )e,en+r+n ,+*i 8i:+) s+6+; 4i)+ 8+-+ 8+n-+n*+n -o)tor 6+n* (+lon ini
'e'erl9)+n r+<+t+n ,i9s # +n+est:esi+$ +t+9 / -+n 8e',e-+:+n se*er+; se-+n*)+n s+6+ ti-+) -+8+t :+-ir 8+-+ '+s+ 6+n* -i8erl9)+n.
.ereby a/thori'ed the medical o--icer to 'i2n on my behal- a' an appro*al to admini'ter anae'the'ia or carry o/t a '/r2ical proced/re
on the applicant in my ab'ence in the e*ent o- an emer2ency a' con-irmed by the attendin2 doctor4 1hen re>/ired.
S+6+ ti-+) +)+n 'en*+',il se,+r+n* tin-+)+n ter:+-+8 Kole4 Uni5ersiti Isl+' M+l+6si+ -+n 'e',e,+s)+n Uni5ersiti ini -+ri
se,+r+n* t9nt9t+n s+'+ +-+ -+ri 8i:+) s+6+ +t+9 8i:+) l+in 4i)+ ,erl+)9 se,+r+n* )e'9n*)in+n 6+n* ti',9l -+ri8+-+ 8rose-9r terse,9t.
I 1ill ab'ol*e ?ole@ Uni*er'iti I'lam Malay'ia o- any claim' -rom my'el- or any other partie' -or any /n-a*o/rable con'e>/ence'
1hich may ari'e -rom the 'aid proced/re!
Di :+-+8+n / In the pre'ence o- Y+n* ,en+r;
T+n-+t+n*+n / ,i2nat/re Yo/r' Faith-/lly4
!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!
#N+'+ S+)si / N+'e of =itness $ T+n-+t+n*+n B+8+/I,9/Pen4+*+
,i2nat/re o- -ather0mother02/radian
No. K+- Pen*en+l+n / P+s8ort S+)si 7 !!!!!!!!!!!!!!!!!!!!!!!!!
I0C "o! 0 Pa''port "o! o- 8itne'' 3 T+ri): 7 AAAAAAAAAAAAAAAAAAAAAA
Date
Al+'+t S+)si 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
A--ress of =itness 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Tndkn 6n2 0e$kitn
Tic( a' rele*ant
>. +( SISTEM RESPIRATORI ' NORMAL
RE,PIRAT#RY ,Y,TEM ABNORMAL !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
,. < =9RA1 DADA ' NORMAL
C.E,T 7:RAY ABNORMAL

< LAMPIRKAN =9RA1 DADA SERTA LAPORAN ->ile% 0es$/ / ATTAC. C.E,T 7:RAY A"D REP#RT (lar2e -ilm$
TARIKH =9RA1 ' DATE X-RAY TEMPAT / PLACE NO( RU*UK =9RA1/ 7:RAY REF! "#!

?. ABDOMEN ; RON!!A HERNIA / NORMAL
A6D#ME" = .ER"IAL #RIFFICE, ABNORMAL
@. SISTEM SARAF DAN MENTAL / NORMAL
"ER;#U, ,Y,TEM A"DME"TAL C#"DITI#" ABNORMAL
A. SISTEM MUSKULOSKELETAL / NORMAL
MU,CUL#,?ELETAL ,Y,TEM ABNORMAL
%B. LAIN9LAIN / OTERS !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
BAHA!IAN ?
PART B
%% PEMERIKSAAN AIR KENCIN! / E&AMINATION OF URINE
!ULA ALBUMIN MICROSCOP1 !!!!!!!!!!!!!!!!!!
,UAR
BAHA!IAN @
PART C
PEN!ESAHAN DOKTOR / Certifi(+tion ,6 Do(tor
Sil tndkn . di dl% kotk 6n2 0e$kenn( Plea'e tic( ) in the appropriate bo+!
S6 %en2eshkn 0h& #d h$i ini s6 telh %e%e$iks 0 I certi-y that I ha*e thi' day ea+mined
AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA No( K'P I/C No. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
dn %end#ti 0h& 3
and -o/nd 3
Beliu tidk %en2hid# #9# #en6kit dn dishkn siht(
The abo*e named i' in 2ood health!
Beliu %en2hid# !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
The abo*e named ha'
Beliu sedn2 %end#t $&tn !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
The abo*e named i' /nder2oin2 treatment
Tndtn2n Dokto$ !!!!!!!!!!!!!!!!!!!!!!
,i2nat/re o- Doctor
N% Dokto$ AAAAAAAAAAAAAAAAAAAAAAAAAAA
TARIKH 3 !!!!!!!!!!!!!!!! "ame o- Doctor
DATE 3 Kelulusn dn Co# Rs%i Klinik !!!!!!!!!!!
D/ali-ication and o--icial 'tamp o- clinic
LAPORAN PEMERIKSAAN KESIHATAN
REPORT OF HEALTH EXAMINATION
SILA ISI DALAM HURUF BESAR
PLEASE FILL IN CAPITALS
Untuk diisi oleh clon
To be completed by the candidate
BAHA!IAN "
Part 1
TAHUN AKADEMIK/ACADEMIC YEAR KOD KURSUS SEMESTER


Se#e$ti dl% su$t t&$n/As in offer letter
FAKULTI'PUSAT'FACULTY NO(PENDAFTARAN/MATRIC (RE! "#$

NAMA PENUH/FULL NAME
NO( KAD PEN!ENALAN 'PASSPORT/IDENTITY CARD/PASSPORT NO. UMUR / AGE

KE)AR!ANE!ARAAN / NATIONALITY TARIKH LAHIR / DATE OF BIRT
LELAKI / MALE PEREMPUAN / FEMALE BU*AN!/ SINGLE KAH)IN / MARRIED
NAMA PEN*A!A / NAME OF GUARDIAN
ALAMAT PEN*A!A / POSTAL ADDRESS OF GUARDIAN
NO( TELEFON RUMAH / OUSE TELEPONE NO. NO( TELEFON PE*ABAT/ OFFICE TELEPONE
BAHA!IAN + , Sil tndkn -./ di kotk 0e$kenn(
PART % & Plea'e tic( ()$ the rele*ant bo+!
Tidk/"o 1/Ye'
Adkh nd'kelu$2 nd %en2l%i 3 Lelh4 0tuk ke$in24 d$h tin22i4 skit 5ntun24 Sendi$i',el-
kencin2 %nis4 skit 0uh #in22n24 2il 00i4 skit 5i&4 #en6lh2unn ddh4 Kelu$2'Family
kecctn n22ot4 knse$4 lhn4 #e%0edhn(
.a*e yo/0yo/r -amily had the -ollo1in2 3 A'thma4 t/berc/lo'i'4 hyperten'ion4 heart di'ea'e'4
diabete' mellit/'4 (idney di'ea'e4 epilep'y4 mental illne''4 dr/2 addiction4 de-ormity4 cancer4
aller2ie'4 operation'!
*ik 14 sil n6tkn / I- ye'4 plea'e 'tate !!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!
S6 den2n ini %en2ku se2l %klu%t kesihtn 6n2 di0e$i di ts dlh 0en$(
( I hereby certi-y that the in-ormation 2i*en abo*e in correct$
"""""""""" #""""""""""""$
#T$ikh/Date$ Tndtn2n
(,i2nat/re o- Candidate$
BAHA!IAN 7 UNTUK DIISI OLEH DOKTOR 1AN! MEMERIKSA Tndkn 6n2 0e$kitn
PART 5 T# 6E FILLED 6Y E7AMI"I" D#CT#R Tic( a' rele*ant
%. PEMERIKSAAN UMUM / GENERAL E&AMINATIONS
TIN!!I/ BERAT /
.EI.T senti'eter/(' 8EI.T )ilo*r+'
PULSE se'init/'in BP ''*
Tndkn 8'9 6n2 0e$kitn
Tic( 90: a' rele*ant
+. PALLOR ,. CYANOSIS (. OEDEMA -. .AUNDICE
e. ENLARGED LYMPNODES f. CRONIC SKIN DISEASE
/( PEMERIKSAAN MATA / KANAN KIRI Cttn Dokto$/;eri-ication o- doctor<' -indin2'
E7AMI"ATI#" #F EYE
+. PEN!LIHATAN TANPA KACA MATA'
U"AIDED ;I,I#"
,. PEN!LIHATAN DEN!AN KACA MATA '
AIDED ;I,I#"
(. FUNDOSCOP1 NORMAL
ABNORMAL
-( PEN!LIHATAN )ARNA' NORMAL
COLOUR :ISION ABDORMAL
0( PEMERIKSAAN TELIN!A NORMAL
E7AMI"ATI#" #F EAR ABNORMAL
1( RUAN! MULUT ; !I!I NORMAL
#RAL CA;ITY = TEET. ABNORMAL
2( *ANTUN! ' .EART NORMAL
ABNORMAL
PERAKUAN KEBENARAN BIUS -ANAESTHESIA/ DAN PEMBEDAHAN
3
AUTORISATION FOR ANATESIA AND SURGICAL PROCEDURE
Pen-+ft+r / Re*istr+r
Kole4 Uni5ersiti Isl+' M+l+6si+
S+6+ 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No. K+- Pen*en+l+n / P+s8ort !!!!!!!!!!!!!!!! B+8+ / I,9 / Pen4+*+ )e8+-+
I0C 0 Pa''port "o! -ather 0 mother 0 2/ardian to
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No. K+- Pen*en+l+n / P+s8ort !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
#N+'+ (+lon / Candidate<' name$ I/C / Pa''port "o!
-en*+n ini 'e',eri )9+s+ )e8+-+ t9+n 9nt9) 'en+n-+t+n*+ni )e,en+r+n ,+*i 8i:+) s+6+; 4i)+ 8+-+ 8+n-+n*+n -o)tor 6+n* (+lon ini
'e'erl9)+n r+<+t+n ,i9s # +n+est:esi+$ +t+9 / -+n 8e',e-+:+n se*er+; se-+n*)+n s+6+ ti-+) -+8+t :+-ir 8+-+ '+s+ 6+n* -i8erl9)+n.
.ereby a/thori'ed the medical o--icer to 'i2n on my behal- a' an appro*al to admini'ter anae'the'ia or carry o/t a '/r2ical proced/re
on the applicant in my ab'ence in the e*ent o- an emer2ency a' con-irmed by the attendin2 doctor4 1hen re>/ired.
S+6+ ti-+) +)+n 'en*+',il se,+r+n* tin-+)+n ter:+-+8 Kole4 Uni5ersiti Isl+' M+l+6si+ -+n 'e',e,+s)+n Uni5ersiti ini -+ri
se,+r+n* t9nt9t+n s+'+ +-+ -+ri 8i:+) s+6+ +t+9 8i:+) l+in 4i)+ ,erl+)9 se,+r+n* )e'9n*)in+n 6+n* ti',9l -+ri8+-+ 8rose-9r terse,9t.
I 1ill ab'ol*e ?ole@ Uni*er'iti I'lam Malay'ia o- any claim' -rom my'el- or any other partie' -or any /n-a*o/rable con'e>/ence'
1hich may ari'e -rom the 'aid proced/re!
Di :+-+8+n / In the pre'ence o- Y+n* ,en+r;
T+n-+t+n*+n / ,i2nat/re Yo/r' Faith-/lly4
!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!
#N+'+ S+)si / N+'e of =itness $ T+n-+t+n*+n B+8+/I,9/Pen4+*+
,i2nat/re o- -ather0mother02/radian
No. K+- Pen*en+l+n / P+s8ort S+)si 7 !!!!!!!!!!!!!!!!!!!!!!!!!
I0C "o! 0 Pa''port "o! o- 8itne'' 3 T+ri): 7 AAAAAAAAAAAAAAAAAAAAAA
Date
Al+'+t S+)si 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
A--ress of =itness 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Tndkn 6n2 0e$kitn
Tic( a' rele*ant
>. +( SISTEM RESPIRATORI ' NORMAL
RE,PIRAT#RY ,Y,TEM ABNORMAL !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
,. < =9RA1 DADA ' NORMAL
C.E,T 7:RAY ABNORMAL

< LAMPIRKAN =9RA1 DADA SERTA LAPORAN ->ile% 0es$/ / ATTAC. C.E,T 7:RAY A"D REP#RT (lar2e -ilm$
TARIKH =9RA1 ' DATE X-RAY TEMPAT / PLACE NO( RU*UK =9RA1/ 7:RAY REF! "#!

?. ABDOMEN ; RON!!A HERNIA / NORMAL
A6D#ME" = .ER"IAL #RIFFICE, ABNORMAL
@. SISTEM SARAF DAN MENTAL / NORMAL
"ER;#U, ,Y,TEM A"DME"TAL C#"DITI#" ABNORMAL
A. SISTEM MUSKULOSKELETAL / NORMAL
MU,CUL#,?ELETAL ,Y,TEM ABNORMAL
%B. LAIN9LAIN / OTERS !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
BAHA!IAN ?
PART B
%% PEMERIKSAAN AIR KENCIN! / E&AMINATION OF URINE
!ULA ALBUMIN MICROSCOP1 !!!!!!!!!!!!!!!!!!
,UAR
BAHA!IAN @
PART C
PEN!ESAHAN DOKTOR / Certifi(+tion ,6 Do(tor
Sil tndkn . di dl% kotk 6n2 0e$kenn( Plea'e tic( ) in the appropriate bo+!
S6 %en2eshkn 0h& #d h$i ini s6 telh %e%e$iks 0 I certi-y that I ha*e thi' day ea+mined
AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA No( K'P I/C No. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
dn %end#ti 0h& 3
and -o/nd 3
Beliu tidk %en2hid# #9# #en6kit dn dishkn siht(
The abo*e named i' in 2ood health!
Beliu %en2hid# !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
The abo*e named ha'
Beliu sedn2 %end#t $&tn !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
The abo*e named i' /nder2oin2 treatment
Tndtn2n Dokto$ !!!!!!!!!!!!!!!!!!!!!!
,i2nat/re o- Doctor
N% Dokto$ AAAAAAAAAAAAAAAAAAAAAAAAAAA
TARIKH 3 !!!!!!!!!!!!!!!! "ame o- Doctor
DATE 3 Kelulusn dn Co# Rs%i Klinik !!!!!!!!!!!
D/ali-ication and o--icial 'tamp o- clinic
LAPORAN PEMERIKSAAN KESIHATAN
REPORT OF HEALTH EXAMINATION
SILA ISI DALAM HURUF BESAR
PLEASE FILL IN CAPITALS
Untuk diisi oleh clon
To be completed by the candidate
BAHA!IAN "
Part 1
TAHUN AKADEMIK/ACADEMIC YEAR KOD KURSUS SEMESTER


Se#e$ti dl% su$t t&$n/As in offer letter
FAKULTI'PUSAT'FACULTY NO(PENDAFTARAN/MATRIC (RE! "#$

NAMA PENUH/FULL NAME
NO( KAD PEN!ENALAN 'PASSPORT/IDENTITY CARD/PASSPORT NO. UMUR / AGE

KE)AR!ANE!ARAAN / NATIONALITY TARIKH LAHIR / DATE OF BIRT
LELAKI / MALE PEREMPUAN / FEMALE BU*AN!/ SINGLE KAH)IN / MARRIED
NAMA PEN*A!A / NAME OF GUARDIAN
ALAMAT PEN*A!A / POSTAL ADDRESS OF GUARDIAN
NO( TELEFON RUMAH / OUSE TELEPONE NO. NO( TELEFON PE*ABAT/ OFFICE TELEPONE
BAHA!IAN + , Sil tndkn -./ di kotk 0e$kenn(
PART % & Plea'e tic( ()$ the rele*ant bo+!
Tidk/"o 1/Ye'
Adkh nd'kelu$2 nd %en2l%i 3 Lelh4 0tuk ke$in24 d$h tin22i4 skit 5ntun24 Sendi$i',el-
kencin2 %nis4 skit 0uh #in22n24 2il 00i4 skit 5i&4 #en6lh2unn ddh4 Kelu$2'Family
kecctn n22ot4 knse$4 lhn4 #e%0edhn(
.a*e yo/0yo/r -amily had the -ollo1in2 3 A'thma4 t/berc/lo'i'4 hyperten'ion4 heart di'ea'e'4
diabete' mellit/'4 (idney di'ea'e4 epilep'y4 mental illne''4 dr/2 addiction4 de-ormity4 cancer4
aller2ie'4 operation'!
*ik 14 sil n6tkn / I- ye'4 plea'e 'tate !!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!
S6 den2n ini %en2ku se2l %klu%t kesihtn 6n2 di0e$i di ts dlh 0en$(
( I hereby certi-y that the in-ormation 2i*en abo*e in correct$
"""""""""" #""""""""""""$
#T$ikh/Date$ Tndtn2n
(,i2nat/re o- Candidate$
BAHA!IAN 7 UNTUK DIISI OLEH DOKTOR 1AN! MEMERIKSA Tndkn 6n2 0e$kitn
PART 5 T# 6E FILLED 6Y E7AMI"I" D#CT#R Tic( a' rele*ant
%. PEMERIKSAAN UMUM / GENERAL E&AMINATIONS
TIN!!I/ BERAT /
.EI.T senti'eter/(' 8EI.T )ilo*r+'
PULSE se'init/'in BP ''*
Tndkn 8'9 6n2 0e$kitn
Tic( 90: a' rele*ant
+. PALLOR ,. CYANOSIS (. OEDEMA -. .AUNDICE
e. ENLARGED LYMPNODES f. CRONIC SKIN DISEASE
/( PEMERIKSAAN MATA / KANAN KIRI Cttn Dokto$/;eri-ication o- doctor<' -indin2'
E7AMI"ATI#" #F EYE
+. PEN!LIHATAN TANPA KACA MATA'
U"AIDED ;I,I#"
,. PEN!LIHATAN DEN!AN KACA MATA '
AIDED ;I,I#"
(. FUNDOSCOP1 NORMAL
ABNORMAL
-( PEN!LIHATAN )ARNA' NORMAL
COLOUR :ISION ABDORMAL
0( PEMERIKSAAN TELIN!A NORMAL
E7AMI"ATI#" #F EAR ABNORMAL
1( RUAN! MULUT ; !I!I NORMAL
#RAL CA;ITY = TEET. ABNORMAL
2( *ANTUN! ' .EART NORMAL
ABNORMAL
PERAKUAN KEBENARAN BIUS -ANAESTHESIA/ DAN PEMBEDAHAN
3
AUTORISATION FOR ANATESIA AND SURGICAL PROCEDURE
Pen-+ft+r / Re*istr+r
Kole4 Uni5ersiti Isl+' M+l+6si+
S+6+ 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No. K+- Pen*en+l+n / P+s8ort !!!!!!!!!!!!!!!! B+8+ / I,9 / Pen4+*+ )e8+-+
I0C 0 Pa''port "o! -ather 0 mother 0 2/ardian to
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No. K+- Pen*en+l+n / P+s8ort !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
#N+'+ (+lon / Candidate<' name$ I/C / Pa''port "o!
-en*+n ini 'e',eri )9+s+ )e8+-+ t9+n 9nt9) 'en+n-+t+n*+ni )e,en+r+n ,+*i 8i:+) s+6+; 4i)+ 8+-+ 8+n-+n*+n -o)tor 6+n* (+lon ini
'e'erl9)+n r+<+t+n ,i9s # +n+est:esi+$ +t+9 / -+n 8e',e-+:+n se*er+; se-+n*)+n s+6+ ti-+) -+8+t :+-ir 8+-+ '+s+ 6+n* -i8erl9)+n.
.ereby a/thori'ed the medical o--icer to 'i2n on my behal- a' an appro*al to admini'ter anae'the'ia or carry o/t a '/r2ical proced/re
on the applicant in my ab'ence in the e*ent o- an emer2ency a' con-irmed by the attendin2 doctor4 1hen re>/ired.
S+6+ ti-+) +)+n 'en*+',il se,+r+n* tin-+)+n ter:+-+8 Kole4 Uni5ersiti Isl+' M+l+6si+ -+n 'e',e,+s)+n Uni5ersiti ini -+ri
se,+r+n* t9nt9t+n s+'+ +-+ -+ri 8i:+) s+6+ +t+9 8i:+) l+in 4i)+ ,erl+)9 se,+r+n* )e'9n*)in+n 6+n* ti',9l -+ri8+-+ 8rose-9r terse,9t.
I 1ill ab'ol*e ?ole@ Uni*er'iti I'lam Malay'ia o- any claim' -rom my'el- or any other partie' -or any /n-a*o/rable con'e>/ence'
1hich may ari'e -rom the 'aid proced/re!
Di :+-+8+n / In the pre'ence o- Y+n* ,en+r;
T+n-+t+n*+n / ,i2nat/re Yo/r' Faith-/lly4
!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!
#N+'+ S+)si / N+'e of =itness $ T+n-+t+n*+n B+8+/I,9/Pen4+*+
,i2nat/re o- -ather0mother02/radian
No. K+- Pen*en+l+n / P+s8ort S+)si 7 !!!!!!!!!!!!!!!!!!!!!!!!!
I0C "o! 0 Pa''port "o! o- 8itne'' 3 T+ri): 7 AAAAAAAAAAAAAAAAAAAAAA
Date
Al+'+t S+)si 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
A--ress of =itness 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Tndkn 6n2 0e$kitn
Tic( a' rele*ant
>. +( SISTEM RESPIRATORI ' NORMAL
RE,PIRAT#RY ,Y,TEM ABNORMAL !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
,. < =9RA1 DADA ' NORMAL
C.E,T 7:RAY ABNORMAL

< LAMPIRKAN =9RA1 DADA SERTA LAPORAN ->ile% 0es$/ / ATTAC. C.E,T 7:RAY A"D REP#RT (lar2e -ilm$
TARIKH =9RA1 ' DATE X-RAY TEMPAT / PLACE NO( RU*UK =9RA1/ 7:RAY REF! "#!

?. ABDOMEN ; RON!!A HERNIA / NORMAL
A6D#ME" = .ER"IAL #RIFFICE, ABNORMAL
@. SISTEM SARAF DAN MENTAL / NORMAL
"ER;#U, ,Y,TEM A"DME"TAL C#"DITI#" ABNORMAL
A. SISTEM MUSKULOSKELETAL / NORMAL
MU,CUL#,?ELETAL ,Y,TEM ABNORMAL
%B. LAIN9LAIN / OTERS !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
BAHA!IAN ?
PART B
%% PEMERIKSAAN AIR KENCIN! / E&AMINATION OF URINE
!ULA ALBUMIN MICROSCOP1 !!!!!!!!!!!!!!!!!!
,UAR
BAHA!IAN @
PART C
PEN!ESAHAN DOKTOR / Certifi(+tion ,6 Do(tor
Sil tndkn . di dl% kotk 6n2 0e$kenn( Plea'e tic( ) in the appropriate bo+!
S6 %en2eshkn 0h& #d h$i ini s6 telh %e%e$iks 0 I certi-y that I ha*e thi' day ea+mined
AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA No( K'P I/C No. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
dn %end#ti 0h& 3
and -o/nd 3
Beliu tidk %en2hid# #9# #en6kit dn dishkn siht(
The abo*e named i' in 2ood health!
Beliu %en2hid# !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
The abo*e named ha'
Beliu sedn2 %end#t $&tn !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
The abo*e named i' /nder2oin2 treatment
Tndtn2n Dokto$ !!!!!!!!!!!!!!!!!!!!!!
,i2nat/re o- Doctor
N% Dokto$ AAAAAAAAAAAAAAAAAAAAAAAAAAA
TARIKH 3 !!!!!!!!!!!!!!!! "ame o- Doctor
DATE 3 Kelulusn dn Co# Rs%i Klinik !!!!!!!!!!!
D/ali-ication and o--icial 'tamp o- clinic
LAPORAN PEMERIKSAAN KESIHATAN
REPORT OF HEALTH EXAMINATION
SILA ISI DALAM HURUF BESAR
PLEASE FILL IN CAPITALS
Untuk diisi oleh clon
To be completed by the candidate
BAHA!IAN "
Part 1
TAHUN AKADEMIK/ACADEMIC YEAR KOD KURSUS SEMESTER


Se#e$ti dl% su$t t&$n/As in offer letter
FAKULTI'PUSAT'FACULTY NO(PENDAFTARAN/MATRIC (RE! "#$

NAMA PENUH/FULL NAME
NO( KAD PEN!ENALAN 'PASSPORT/IDENTITY CARD/PASSPORT NO. UMUR / AGE

KE)AR!ANE!ARAAN / NATIONALITY TARIKH LAHIR / DATE OF BIRT
LELAKI / MALE PEREMPUAN / FEMALE BU*AN!/ SINGLE KAH)IN / MARRIED
NAMA PEN*A!A / NAME OF GUARDIAN
ALAMAT PEN*A!A / POSTAL ADDRESS OF GUARDIAN
NO( TELEFON RUMAH / OUSE TELEPONE NO. NO( TELEFON PE*ABAT/ OFFICE TELEPONE
BAHA!IAN + , Sil tndkn -./ di kotk 0e$kenn(
PART % & Plea'e tic( ()$ the rele*ant bo+!
Tidk/"o 1/Ye'
Adkh nd'kelu$2 nd %en2l%i 3 Lelh4 0tuk ke$in24 d$h tin22i4 skit 5ntun24 Sendi$i',el-
kencin2 %nis4 skit 0uh #in22n24 2il 00i4 skit 5i&4 #en6lh2unn ddh4 Kelu$2'Family
kecctn n22ot4 knse$4 lhn4 #e%0edhn(
.a*e yo/0yo/r -amily had the -ollo1in2 3 A'thma4 t/berc/lo'i'4 hyperten'ion4 heart di'ea'e'4
diabete' mellit/'4 (idney di'ea'e4 epilep'y4 mental illne''4 dr/2 addiction4 de-ormity4 cancer4
aller2ie'4 operation'!
*ik 14 sil n6tkn / I- ye'4 plea'e 'tate !!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!
S6 den2n ini %en2ku se2l %klu%t kesihtn 6n2 di0e$i di ts dlh 0en$(
( I hereby certi-y that the in-ormation 2i*en abo*e in correct$
"""""""""" #""""""""""""$
#T$ikh/Date$ Tndtn2n
(,i2nat/re o- Candidate$
BAHA!IAN 7 UNTUK DIISI OLEH DOKTOR 1AN! MEMERIKSA Tndkn 6n2 0e$kitn
PART 5 T# 6E FILLED 6Y E7AMI"I" D#CT#R Tic( a' rele*ant
%. PEMERIKSAAN UMUM / GENERAL E&AMINATIONS
TIN!!I/ BERAT /
.EI.T senti'eter/(' 8EI.T )ilo*r+'
PULSE se'init/'in BP ''*
Tndkn 8'9 6n2 0e$kitn
Tic( 90: a' rele*ant
+. PALLOR ,. CYANOSIS (. OEDEMA -. .AUNDICE
e. ENLARGED LYMPNODES f. CRONIC SKIN DISEASE
/( PEMERIKSAAN MATA / KANAN KIRI Cttn Dokto$/;eri-ication o- doctor<' -indin2'
E7AMI"ATI#" #F EYE
+. PEN!LIHATAN TANPA KACA MATA'
U"AIDED ;I,I#"
,. PEN!LIHATAN DEN!AN KACA MATA '
AIDED ;I,I#"
(. FUNDOSCOP1 NORMAL
ABNORMAL
-( PEN!LIHATAN )ARNA' NORMAL
COLOUR :ISION ABDORMAL
0( PEMERIKSAAN TELIN!A NORMAL
E7AMI"ATI#" #F EAR ABNORMAL
1( RUAN! MULUT ; !I!I NORMAL
#RAL CA;ITY = TEET. ABNORMAL
2( *ANTUN! ' .EART NORMAL
ABNORMAL
PERAKUAN KEBENARAN BIUS -ANAESTHESIA/ DAN PEMBEDAHAN
3
AUTORISATION FOR ANATESIA AND SURGICAL PROCEDURE
Pen-+ft+r / Re*istr+r
Kole4 Uni5ersiti Isl+' M+l+6si+
S+6+ 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No. K+- Pen*en+l+n / P+s8ort !!!!!!!!!!!!!!!! B+8+ / I,9 / Pen4+*+ )e8+-+
I0C 0 Pa''port "o! -ather 0 mother 0 2/ardian to
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No. K+- Pen*en+l+n / P+s8ort !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
#N+'+ (+lon / Candidate<' name$ I/C / Pa''port "o!
-en*+n ini 'e',eri )9+s+ )e8+-+ t9+n 9nt9) 'en+n-+t+n*+ni )e,en+r+n ,+*i 8i:+) s+6+; 4i)+ 8+-+ 8+n-+n*+n -o)tor 6+n* (+lon ini
'e'erl9)+n r+<+t+n ,i9s # +n+est:esi+$ +t+9 / -+n 8e',e-+:+n se*er+; se-+n*)+n s+6+ ti-+) -+8+t :+-ir 8+-+ '+s+ 6+n* -i8erl9)+n.
.ereby a/thori'ed the medical o--icer to 'i2n on my behal- a' an appro*al to admini'ter anae'the'ia or carry o/t a '/r2ical proced/re
on the applicant in my ab'ence in the e*ent o- an emer2ency a' con-irmed by the attendin2 doctor4 1hen re>/ired.
S+6+ ti-+) +)+n 'en*+',il se,+r+n* tin-+)+n ter:+-+8 Kole4 Uni5ersiti Isl+' M+l+6si+ -+n 'e',e,+s)+n Uni5ersiti ini -+ri
se,+r+n* t9nt9t+n s+'+ +-+ -+ri 8i:+) s+6+ +t+9 8i:+) l+in 4i)+ ,erl+)9 se,+r+n* )e'9n*)in+n 6+n* ti',9l -+ri8+-+ 8rose-9r terse,9t.
I 1ill ab'ol*e ?ole@ Uni*er'iti I'lam Malay'ia o- any claim' -rom my'el- or any other partie' -or any /n-a*o/rable con'e>/ence'
1hich may ari'e -rom the 'aid proced/re!
Di :+-+8+n / In the pre'ence o- Y+n* ,en+r;
T+n-+t+n*+n / ,i2nat/re Yo/r' Faith-/lly4
!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!
#N+'+ S+)si / N+'e of =itness $ T+n-+t+n*+n B+8+/I,9/Pen4+*+
,i2nat/re o- -ather0mother02/radian
No. K+- Pen*en+l+n / P+s8ort S+)si 7 !!!!!!!!!!!!!!!!!!!!!!!!!
I0C "o! 0 Pa''port "o! o- 8itne'' 3 T+ri): 7 AAAAAAAAAAAAAAAAAAAAAA
Date
Al+'+t S+)si 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
A--ress of =itness 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Tndkn 6n2 0e$kitn
Tic( a' rele*ant
>. +( SISTEM RESPIRATORI ' NORMAL
RE,PIRAT#RY ,Y,TEM ABNORMAL !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
,. < =9RA1 DADA ' NORMAL
C.E,T 7:RAY ABNORMAL

< LAMPIRKAN =9RA1 DADA SERTA LAPORAN ->ile% 0es$/ / ATTAC. C.E,T 7:RAY A"D REP#RT (lar2e -ilm$
TARIKH =9RA1 ' DATE X-RAY TEMPAT / PLACE NO( RU*UK =9RA1/ 7:RAY REF! "#!

?. ABDOMEN ; RON!!A HERNIA / NORMAL
A6D#ME" = .ER"IAL #RIFFICE, ABNORMAL
@. SISTEM SARAF DAN MENTAL / NORMAL
"ER;#U, ,Y,TEM A"DME"TAL C#"DITI#" ABNORMAL
A. SISTEM MUSKULOSKELETAL / NORMAL
MU,CUL#,?ELETAL ,Y,TEM ABNORMAL
%B. LAIN9LAIN / OTERS !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
BAHA!IAN ?
PART B
%% PEMERIKSAAN AIR KENCIN! / E&AMINATION OF URINE
!ULA ALBUMIN MICROSCOP1 !!!!!!!!!!!!!!!!!!
,UAR
BAHA!IAN @
PART C
PEN!ESAHAN DOKTOR / Certifi(+tion ,6 Do(tor
Sil tndkn . di dl% kotk 6n2 0e$kenn( Plea'e tic( ) in the appropriate bo+!
S6 %en2eshkn 0h& #d h$i ini s6 telh %e%e$iks 0 I certi-y that I ha*e thi' day ea+mined
AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA No( K'P I/C No. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
dn %end#ti 0h& 3
and -o/nd 3
Beliu tidk %en2hid# #9# #en6kit dn dishkn siht(
The abo*e named i' in 2ood health!
Beliu %en2hid# !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
The abo*e named ha'
Beliu sedn2 %end#t $&tn !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
The abo*e named i' /nder2oin2 treatment
Tndtn2n Dokto$ !!!!!!!!!!!!!!!!!!!!!!
,i2nat/re o- Doctor
N% Dokto$ AAAAAAAAAAAAAAAAAAAAAAAAAAA
TARIKH 3 !!!!!!!!!!!!!!!! "ame o- Doctor
DATE 3 Kelulusn dn Co# Rs%i Klinik !!!!!!!!!!!
D/ali-ication and o--icial 'tamp o- clinic
LAPORAN PEMERIKSAAN KESIHATAN
REPORT OF HEALTH EXAMINATION
SILA ISI DALAM HURUF BESAR
PLEASE FILL IN CAPITALS
Untuk diisi oleh clon
To be completed by the candidate
BAHA!IAN "
Part 1
TAHUN AKADEMIK/ACADEMIC YEAR KOD KURSUS SEMESTER


Se#e$ti dl% su$t t&$n/As in offer letter
FAKULTI'PUSAT'FACULTY NO(PENDAFTARAN/MATRIC (RE! "#$

NAMA PENUH/FULL NAME
NO( KAD PEN!ENALAN 'PASSPORT/IDENTITY CARD/PASSPORT NO. UMUR / AGE

KE)AR!ANE!ARAAN / NATIONALITY TARIKH LAHIR / DATE OF BIRT
LELAKI / MALE PEREMPUAN / FEMALE BU*AN!/ SINGLE KAH)IN / MARRIED
NAMA PEN*A!A / NAME OF GUARDIAN
ALAMAT PEN*A!A / POSTAL ADDRESS OF GUARDIAN
NO( TELEFON RUMAH / OUSE TELEPONE NO. NO( TELEFON PE*ABAT/ OFFICE TELEPONE
BAHA!IAN + , Sil tndkn -./ di kotk 0e$kenn(
PART % & Plea'e tic( ()$ the rele*ant bo+!
Tidk/"o 1/Ye'
Adkh nd'kelu$2 nd %en2l%i 3 Lelh4 0tuk ke$in24 d$h tin22i4 skit 5ntun24 Sendi$i',el-
kencin2 %nis4 skit 0uh #in22n24 2il 00i4 skit 5i&4 #en6lh2unn ddh4 Kelu$2'Family
kecctn n22ot4 knse$4 lhn4 #e%0edhn(
.a*e yo/0yo/r -amily had the -ollo1in2 3 A'thma4 t/berc/lo'i'4 hyperten'ion4 heart di'ea'e'4
diabete' mellit/'4 (idney di'ea'e4 epilep'y4 mental illne''4 dr/2 addiction4 de-ormity4 cancer4
aller2ie'4 operation'!
*ik 14 sil n6tkn / I- ye'4 plea'e 'tate !!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!
S6 den2n ini %en2ku se2l %klu%t kesihtn 6n2 di0e$i di ts dlh 0en$(
( I hereby certi-y that the in-ormation 2i*en abo*e in correct$
"""""""""" #""""""""""""$
#T$ikh/Date$ Tndtn2n
(,i2nat/re o- Candidate$
BAHA!IAN 7 UNTUK DIISI OLEH DOKTOR 1AN! MEMERIKSA Tndkn 6n2 0e$kitn
PART 5 T# 6E FILLED 6Y E7AMI"I" D#CT#R Tic( a' rele*ant
%. PEMERIKSAAN UMUM / GENERAL E&AMINATIONS
TIN!!I/ BERAT /
.EI.T senti'eter/(' 8EI.T )ilo*r+'
PULSE se'init/'in BP ''*
Tndkn 8'9 6n2 0e$kitn
Tic( 90: a' rele*ant
+. PALLOR ,. CYANOSIS (. OEDEMA -. .AUNDICE
e. ENLARGED LYMPNODES f. CRONIC SKIN DISEASE
/( PEMERIKSAAN MATA / KANAN KIRI Cttn Dokto$/;eri-ication o- doctor<' -indin2'
E7AMI"ATI#" #F EYE
+. PEN!LIHATAN TANPA KACA MATA'
U"AIDED ;I,I#"
,. PEN!LIHATAN DEN!AN KACA MATA '
AIDED ;I,I#"
(. FUNDOSCOP1 NORMAL
ABNORMAL
-( PEN!LIHATAN )ARNA' NORMAL
COLOUR :ISION ABDORMAL
0( PEMERIKSAAN TELIN!A NORMAL
E7AMI"ATI#" #F EAR ABNORMAL
1( RUAN! MULUT ; !I!I NORMAL
#RAL CA;ITY = TEET. ABNORMAL
2( *ANTUN! ' .EART NORMAL
ABNORMAL
PERAKUAN KEBENARAN BIUS -ANAESTHESIA/ DAN PEMBEDAHAN
3
AUTORISATION FOR ANATESIA AND SURGICAL PROCEDURE
Pen-+ft+r / Re*istr+r
Kole4 Uni5ersiti Isl+' M+l+6si+
S+6+ 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No. K+- Pen*en+l+n / P+s8ort !!!!!!!!!!!!!!!! B+8+ / I,9 / Pen4+*+ )e8+-+
I0C 0 Pa''port "o! -ather 0 mother 0 2/ardian to
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No. K+- Pen*en+l+n / P+s8ort !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
#N+'+ (+lon / Candidate<' name$ I/C / Pa''port "o!
-en*+n ini 'e',eri )9+s+ )e8+-+ t9+n 9nt9) 'en+n-+t+n*+ni )e,en+r+n ,+*i 8i:+) s+6+; 4i)+ 8+-+ 8+n-+n*+n -o)tor 6+n* (+lon ini
'e'erl9)+n r+<+t+n ,i9s # +n+est:esi+$ +t+9 / -+n 8e',e-+:+n se*er+; se-+n*)+n s+6+ ti-+) -+8+t :+-ir 8+-+ '+s+ 6+n* -i8erl9)+n.
.ereby a/thori'ed the medical o--icer to 'i2n on my behal- a' an appro*al to admini'ter anae'the'ia or carry o/t a '/r2ical proced/re
on the applicant in my ab'ence in the e*ent o- an emer2ency a' con-irmed by the attendin2 doctor4 1hen re>/ired.
S+6+ ti-+) +)+n 'en*+',il se,+r+n* tin-+)+n ter:+-+8 Kole4 Uni5ersiti Isl+' M+l+6si+ -+n 'e',e,+s)+n Uni5ersiti ini -+ri
se,+r+n* t9nt9t+n s+'+ +-+ -+ri 8i:+) s+6+ +t+9 8i:+) l+in 4i)+ ,erl+)9 se,+r+n* )e'9n*)in+n 6+n* ti',9l -+ri8+-+ 8rose-9r terse,9t.
I 1ill ab'ol*e ?ole@ Uni*er'iti I'lam Malay'ia o- any claim' -rom my'el- or any other partie' -or any /n-a*o/rable con'e>/ence'
1hich may ari'e -rom the 'aid proced/re!
Di :+-+8+n / In the pre'ence o- Y+n* ,en+r;
T+n-+t+n*+n / ,i2nat/re Yo/r' Faith-/lly4
!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!
#N+'+ S+)si / N+'e of =itness $ T+n-+t+n*+n B+8+/I,9/Pen4+*+
,i2nat/re o- -ather0mother02/radian
No. K+- Pen*en+l+n / P+s8ort S+)si 7 !!!!!!!!!!!!!!!!!!!!!!!!!
I0C "o! 0 Pa''port "o! o- 8itne'' 3 T+ri): 7 AAAAAAAAAAAAAAAAAAAAAA
Date
Al+'+t S+)si 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
A--ress of =itness 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Tndkn 6n2 0e$kitn
Tic( a' rele*ant
>. +( SISTEM RESPIRATORI ' NORMAL
RE,PIRAT#RY ,Y,TEM ABNORMAL !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
,. < =9RA1 DADA ' NORMAL
C.E,T 7:RAY ABNORMAL

< LAMPIRKAN =9RA1 DADA SERTA LAPORAN ->ile% 0es$/ / ATTAC. C.E,T 7:RAY A"D REP#RT (lar2e -ilm$
TARIKH =9RA1 ' DATE X-RAY TEMPAT / PLACE NO( RU*UK =9RA1/ 7:RAY REF! "#!

?. ABDOMEN ; RON!!A HERNIA / NORMAL
A6D#ME" = .ER"IAL #RIFFICE, ABNORMAL
@. SISTEM SARAF DAN MENTAL / NORMAL
"ER;#U, ,Y,TEM A"DME"TAL C#"DITI#" ABNORMAL
A. SISTEM MUSKULOSKELETAL / NORMAL
MU,CUL#,?ELETAL ,Y,TEM ABNORMAL
%B. LAIN9LAIN / OTERS !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
BAHA!IAN ?
PART B
%% PEMERIKSAAN AIR KENCIN! / E&AMINATION OF URINE
!ULA ALBUMIN MICROSCOP1 !!!!!!!!!!!!!!!!!!
,UAR
BAHA!IAN @
PART C
PEN!ESAHAN DOKTOR / Certifi(+tion ,6 Do(tor
Sil tndkn . di dl% kotk 6n2 0e$kenn( Plea'e tic( ) in the appropriate bo+!
S6 %en2eshkn 0h& #d h$i ini s6 telh %e%e$iks 0 I certi-y that I ha*e thi' day ea+mined
AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA No( K'P I/C No. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
dn %end#ti 0h& 3
and -o/nd 3
Beliu tidk %en2hid# #9# #en6kit dn dishkn siht(
The abo*e named i' in 2ood health!
Beliu %en2hid# !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
The abo*e named ha'
Beliu sedn2 %end#t $&tn !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
The abo*e named i' /nder2oin2 treatment
Tndtn2n Dokto$ !!!!!!!!!!!!!!!!!!!!!!
,i2nat/re o- Doctor
N% Dokto$ AAAAAAAAAAAAAAAAAAAAAAAAAAA
TARIKH 3 !!!!!!!!!!!!!!!! "ame o- Doctor
DATE 3 Kelulusn dn Co# Rs%i Klinik !!!!!!!!!!!
D/ali-ication and o--icial 'tamp o- clinic
LAPORAN PEMERIKSAAN KESIHATAN
REPORT OF HEALTH EXAMINATION
SILA ISI DALAM HURUF BESAR
PLEASE FILL IN CAPITALS
Untuk diisi oleh clon
To be completed by the candidate
BAHA!IAN "
Part 1
TAHUN AKADEMIK/ACADEMIC YEAR KOD KURSUS SEMESTER


Se#e$ti dl% su$t t&$n/As in offer letter
FAKULTI'PUSAT'FACULTY NO(PENDAFTARAN/MATRIC (RE! "#$

NAMA PENUH/FULL NAME
NO( KAD PEN!ENALAN 'PASSPORT/IDENTITY CARD/PASSPORT NO. UMUR / AGE

KE)AR!ANE!ARAAN / NATIONALITY TARIKH LAHIR / DATE OF BIRT
LELAKI / MALE PEREMPUAN / FEMALE BU*AN!/ SINGLE KAH)IN / MARRIED
NAMA PEN*A!A / NAME OF GUARDIAN
ALAMAT PEN*A!A / POSTAL ADDRESS OF GUARDIAN
NO( TELEFON RUMAH / OUSE TELEPONE NO. NO( TELEFON PE*ABAT/ OFFICE TELEPONE
BAHA!IAN + , Sil tndkn -./ di kotk 0e$kenn(
PART % & Plea'e tic( ()$ the rele*ant bo+!
Tidk/"o 1/Ye'
Adkh nd'kelu$2 nd %en2l%i 3 Lelh4 0tuk ke$in24 d$h tin22i4 skit 5ntun24 Sendi$i',el-
kencin2 %nis4 skit 0uh #in22n24 2il 00i4 skit 5i&4 #en6lh2unn ddh4 Kelu$2'Family
kecctn n22ot4 knse$4 lhn4 #e%0edhn(
.a*e yo/0yo/r -amily had the -ollo1in2 3 A'thma4 t/berc/lo'i'4 hyperten'ion4 heart di'ea'e'4
diabete' mellit/'4 (idney di'ea'e4 epilep'y4 mental illne''4 dr/2 addiction4 de-ormity4 cancer4
aller2ie'4 operation'!
*ik 14 sil n6tkn / I- ye'4 plea'e 'tate !!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!
S6 den2n ini %en2ku se2l %klu%t kesihtn 6n2 di0e$i di ts dlh 0en$(
( I hereby certi-y that the in-ormation 2i*en abo*e in correct$
"""""""""" #""""""""""""$
#T$ikh/Date$ Tndtn2n
(,i2nat/re o- Candidate$
BAHA!IAN 7 UNTUK DIISI OLEH DOKTOR 1AN! MEMERIKSA Tndkn 6n2 0e$kitn
PART 5 T# 6E FILLED 6Y E7AMI"I" D#CT#R Tic( a' rele*ant
%. PEMERIKSAAN UMUM / GENERAL E&AMINATIONS
TIN!!I/ BERAT /
.EI.T senti'eter/(' 8EI.T )ilo*r+'
PULSE se'init/'in BP ''*
Tndkn 8'9 6n2 0e$kitn
Tic( 90: a' rele*ant
+. PALLOR ,. CYANOSIS (. OEDEMA -. .AUNDICE
e. ENLARGED LYMPNODES f. CRONIC SKIN DISEASE
/( PEMERIKSAAN MATA / KANAN KIRI Cttn Dokto$/;eri-ication o- doctor<' -indin2'
E7AMI"ATI#" #F EYE
+. PEN!LIHATAN TANPA KACA MATA'
U"AIDED ;I,I#"
,. PEN!LIHATAN DEN!AN KACA MATA '
AIDED ;I,I#"
(. FUNDOSCOP1 NORMAL
ABNORMAL
-( PEN!LIHATAN )ARNA' NORMAL
COLOUR :ISION ABDORMAL
0( PEMERIKSAAN TELIN!A NORMAL
E7AMI"ATI#" #F EAR ABNORMAL
1( RUAN! MULUT ; !I!I NORMAL
#RAL CA;ITY = TEET. ABNORMAL
2( *ANTUN! ' .EART NORMAL
ABNORMAL
PERAKUAN KEBENARAN BIUS -ANAESTHESIA/ DAN PEMBEDAHAN
3
AUTORISATION FOR ANATESIA AND SURGICAL PROCEDURE
Pen-+ft+r / Re*istr+r
Kole4 Uni5ersiti Isl+' M+l+6si+
S+6+ 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No. K+- Pen*en+l+n / P+s8ort !!!!!!!!!!!!!!!! B+8+ / I,9 / Pen4+*+ )e8+-+
I0C 0 Pa''port "o! -ather 0 mother 0 2/ardian to
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No. K+- Pen*en+l+n / P+s8ort !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
#N+'+ (+lon / Candidate<' name$ I/C / Pa''port "o!
-en*+n ini 'e',eri )9+s+ )e8+-+ t9+n 9nt9) 'en+n-+t+n*+ni )e,en+r+n ,+*i 8i:+) s+6+; 4i)+ 8+-+ 8+n-+n*+n -o)tor 6+n* (+lon ini
'e'erl9)+n r+<+t+n ,i9s # +n+est:esi+$ +t+9 / -+n 8e',e-+:+n se*er+; se-+n*)+n s+6+ ti-+) -+8+t :+-ir 8+-+ '+s+ 6+n* -i8erl9)+n.
.ereby a/thori'ed the medical o--icer to 'i2n on my behal- a' an appro*al to admini'ter anae'the'ia or carry o/t a '/r2ical proced/re
on the applicant in my ab'ence in the e*ent o- an emer2ency a' con-irmed by the attendin2 doctor4 1hen re>/ired.
S+6+ ti-+) +)+n 'en*+',il se,+r+n* tin-+)+n ter:+-+8 Kole4 Uni5ersiti Isl+' M+l+6si+ -+n 'e',e,+s)+n Uni5ersiti ini -+ri
se,+r+n* t9nt9t+n s+'+ +-+ -+ri 8i:+) s+6+ +t+9 8i:+) l+in 4i)+ ,erl+)9 se,+r+n* )e'9n*)in+n 6+n* ti',9l -+ri8+-+ 8rose-9r terse,9t.
I 1ill ab'ol*e ?ole@ Uni*er'iti I'lam Malay'ia o- any claim' -rom my'el- or any other partie' -or any /n-a*o/rable con'e>/ence'
1hich may ari'e -rom the 'aid proced/re!
Di :+-+8+n / In the pre'ence o- Y+n* ,en+r;
T+n-+t+n*+n / ,i2nat/re Yo/r' Faith-/lly4
!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!
#N+'+ S+)si / N+'e of =itness $ T+n-+t+n*+n B+8+/I,9/Pen4+*+
,i2nat/re o- -ather0mother02/radian
No. K+- Pen*en+l+n / P+s8ort S+)si 7 !!!!!!!!!!!!!!!!!!!!!!!!!
I0C "o! 0 Pa''port "o! o- 8itne'' 3 T+ri): 7 AAAAAAAAAAAAAAAAAAAAAA
Date
Al+'+t S+)si 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
A--ress of =itness 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Tndkn 6n2 0e$kitn
Tic( a' rele*ant
>. +( SISTEM RESPIRATORI ' NORMAL
RE,PIRAT#RY ,Y,TEM ABNORMAL !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
,. < =9RA1 DADA ' NORMAL
C.E,T 7:RAY ABNORMAL

< LAMPIRKAN =9RA1 DADA SERTA LAPORAN ->ile% 0es$/ / ATTAC. C.E,T 7:RAY A"D REP#RT (lar2e -ilm$
TARIKH =9RA1 ' DATE X-RAY TEMPAT / PLACE NO( RU*UK =9RA1/ 7:RAY REF! "#!

?. ABDOMEN ; RON!!A HERNIA / NORMAL
A6D#ME" = .ER"IAL #RIFFICE, ABNORMAL
@. SISTEM SARAF DAN MENTAL / NORMAL
"ER;#U, ,Y,TEM A"DME"TAL C#"DITI#" ABNORMAL
A. SISTEM MUSKULOSKELETAL / NORMAL
MU,CUL#,?ELETAL ,Y,TEM ABNORMAL
%B. LAIN9LAIN / OTERS !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
BAHA!IAN ?
PART B
%% PEMERIKSAAN AIR KENCIN! / E&AMINATION OF URINE
!ULA ALBUMIN MICROSCOP1 !!!!!!!!!!!!!!!!!!
,UAR
BAHA!IAN @
PART C
PEN!ESAHAN DOKTOR / Certifi(+tion ,6 Do(tor
Sil tndkn . di dl% kotk 6n2 0e$kenn( Plea'e tic( ) in the appropriate bo+!
S6 %en2eshkn 0h& #d h$i ini s6 telh %e%e$iks 0 I certi-y that I ha*e thi' day ea+mined
AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA No( K'P I/C No. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
dn %end#ti 0h& 3
and -o/nd 3
Beliu tidk %en2hid# #9# #en6kit dn dishkn siht(
The abo*e named i' in 2ood health!
Beliu %en2hid# !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
The abo*e named ha'
Beliu sedn2 %end#t $&tn !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
The abo*e named i' /nder2oin2 treatment
Tndtn2n Dokto$ !!!!!!!!!!!!!!!!!!!!!!
,i2nat/re o- Doctor
N% Dokto$ AAAAAAAAAAAAAAAAAAAAAAAAAAA
TARIKH 3 !!!!!!!!!!!!!!!! "ame o- Doctor
DATE 3 Kelulusn dn Co# Rs%i Klinik !!!!!!!!!!!
D/ali-ication and o--icial 'tamp o- clinic
LAPORAN PEMERIKSAAN KESIHATAN
REPORT OF HEALTH EXAMINATION
SILA ISI DALAM HURUF BESAR
PLEASE FILL IN CAPITALS
Untuk diisi oleh clon
To be completed by the candidate
BAHA!IAN "
Part 1
TAHUN AKADEMIK/ACADEMIC YEAR KOD KURSUS SEMESTER


Se#e$ti dl% su$t t&$n/As in offer letter
FAKULTI'PUSAT'FACULTY NO(PENDAFTARAN/MATRIC (RE! "#$

NAMA PENUH/FULL NAME
NO( KAD PEN!ENALAN 'PASSPORT/IDENTITY CARD/PASSPORT NO. UMUR / AGE

KE)AR!ANE!ARAAN / NATIONALITY TARIKH LAHIR / DATE OF BIRT
LELAKI / MALE PEREMPUAN / FEMALE BU*AN!/ SINGLE KAH)IN / MARRIED
NAMA PEN*A!A / NAME OF GUARDIAN
ALAMAT PEN*A!A / POSTAL ADDRESS OF GUARDIAN
NO( TELEFON RUMAH / OUSE TELEPONE NO. NO( TELEFON PE*ABAT/ OFFICE TELEPONE
BAHA!IAN + , Sil tndkn -./ di kotk 0e$kenn(
PART % & Plea'e tic( ()$ the rele*ant bo+!
Tidk/"o 1/Ye'
Adkh nd'kelu$2 nd %en2l%i 3 Lelh4 0tuk ke$in24 d$h tin22i4 skit 5ntun24 Sendi$i',el-
kencin2 %nis4 skit 0uh #in22n24 2il 00i4 skit 5i&4 #en6lh2unn ddh4 Kelu$2'Family
kecctn n22ot4 knse$4 lhn4 #e%0edhn(
.a*e yo/0yo/r -amily had the -ollo1in2 3 A'thma4 t/berc/lo'i'4 hyperten'ion4 heart di'ea'e'4
diabete' mellit/'4 (idney di'ea'e4 epilep'y4 mental illne''4 dr/2 addiction4 de-ormity4 cancer4
aller2ie'4 operation'!
*ik 14 sil n6tkn / I- ye'4 plea'e 'tate !!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!
S6 den2n ini %en2ku se2l %klu%t kesihtn 6n2 di0e$i di ts dlh 0en$(
( I hereby certi-y that the in-ormation 2i*en abo*e in correct$
"""""""""" #""""""""""""$
#T$ikh/Date$ Tndtn2n
(,i2nat/re o- Candidate$
BAHA!IAN 7 UNTUK DIISI OLEH DOKTOR 1AN! MEMERIKSA Tndkn 6n2 0e$kitn
PART 5 T# 6E FILLED 6Y E7AMI"I" D#CT#R Tic( a' rele*ant
%. PEMERIKSAAN UMUM / GENERAL E&AMINATIONS
TIN!!I/ BERAT /
.EI.T senti'eter/(' 8EI.T )ilo*r+'
PULSE se'init/'in BP ''*
Tndkn 8'9 6n2 0e$kitn
Tic( 90: a' rele*ant
+. PALLOR ,. CYANOSIS (. OEDEMA -. .AUNDICE
e. ENLARGED LYMPNODES f. CRONIC SKIN DISEASE
/( PEMERIKSAAN MATA / KANAN KIRI Cttn Dokto$/;eri-ication o- doctor<' -indin2'
E7AMI"ATI#" #F EYE
+. PEN!LIHATAN TANPA KACA MATA'
U"AIDED ;I,I#"
,. PEN!LIHATAN DEN!AN KACA MATA '
AIDED ;I,I#"
(. FUNDOSCOP1 NORMAL
ABNORMAL
-( PEN!LIHATAN )ARNA' NORMAL
COLOUR :ISION ABDORMAL
0( PEMERIKSAAN TELIN!A NORMAL
E7AMI"ATI#" #F EAR ABNORMAL
1( RUAN! MULUT ; !I!I NORMAL
#RAL CA;ITY = TEET. ABNORMAL
2( *ANTUN! ' .EART NORMAL
ABNORMAL
PERAKUAN KEBENARAN BIUS -ANAESTHESIA/ DAN PEMBEDAHAN
3
AUTORISATION FOR ANATESIA AND SURGICAL PROCEDURE
Pen-+ft+r / Re*istr+r
Kole4 Uni5ersiti Isl+' M+l+6si+
S+6+ 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No. K+- Pen*en+l+n / P+s8ort !!!!!!!!!!!!!!!! B+8+ / I,9 / Pen4+*+ )e8+-+
I0C 0 Pa''port "o! -ather 0 mother 0 2/ardian to
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No. K+- Pen*en+l+n / P+s8ort !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
#N+'+ (+lon / Candidate<' name$ I/C / Pa''port "o!
-en*+n ini 'e',eri )9+s+ )e8+-+ t9+n 9nt9) 'en+n-+t+n*+ni )e,en+r+n ,+*i 8i:+) s+6+; 4i)+ 8+-+ 8+n-+n*+n -o)tor 6+n* (+lon ini
'e'erl9)+n r+<+t+n ,i9s # +n+est:esi+$ +t+9 / -+n 8e',e-+:+n se*er+; se-+n*)+n s+6+ ti-+) -+8+t :+-ir 8+-+ '+s+ 6+n* -i8erl9)+n.
.ereby a/thori'ed the medical o--icer to 'i2n on my behal- a' an appro*al to admini'ter anae'the'ia or carry o/t a '/r2ical proced/re
on the applicant in my ab'ence in the e*ent o- an emer2ency a' con-irmed by the attendin2 doctor4 1hen re>/ired.
S+6+ ti-+) +)+n 'en*+',il se,+r+n* tin-+)+n ter:+-+8 Kole4 Uni5ersiti Isl+' M+l+6si+ -+n 'e',e,+s)+n Uni5ersiti ini -+ri
se,+r+n* t9nt9t+n s+'+ +-+ -+ri 8i:+) s+6+ +t+9 8i:+) l+in 4i)+ ,erl+)9 se,+r+n* )e'9n*)in+n 6+n* ti',9l -+ri8+-+ 8rose-9r terse,9t.
I 1ill ab'ol*e ?ole@ Uni*er'iti I'lam Malay'ia o- any claim' -rom my'el- or any other partie' -or any /n-a*o/rable con'e>/ence'
1hich may ari'e -rom the 'aid proced/re!
Di :+-+8+n / In the pre'ence o- Y+n* ,en+r;
T+n-+t+n*+n / ,i2nat/re Yo/r' Faith-/lly4
!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!
#N+'+ S+)si / N+'e of =itness $ T+n-+t+n*+n B+8+/I,9/Pen4+*+
,i2nat/re o- -ather0mother02/radian
No. K+- Pen*en+l+n / P+s8ort S+)si 7 !!!!!!!!!!!!!!!!!!!!!!!!!
I0C "o! 0 Pa''port "o! o- 8itne'' 3 T+ri): 7 AAAAAAAAAAAAAAAAAAAAAA
Date
Al+'+t S+)si 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
A--ress of =itness 7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Tndkn 6n2 0e$kitn
Tic( a' rele*ant
>. +( SISTEM RESPIRATORI ' NORMAL
RE,PIRAT#RY ,Y,TEM ABNORMAL !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
,. < =9RA1 DADA ' NORMAL
C.E,T 7:RAY ABNORMAL

< LAMPIRKAN =9RA1 DADA SERTA LAPORAN ->ile% 0es$/ / ATTAC. C.E,T 7:RAY A"D REP#RT (lar2e -ilm$
TARIKH =9RA1 ' DATE X-RAY TEMPAT / PLACE NO( RU*UK =9RA1/ 7:RAY REF! "#!

?. ABDOMEN ; RON!!A HERNIA / NORMAL
A6D#ME" = .ER"IAL #RIFFICE, ABNORMAL
@. SISTEM SARAF DAN MENTAL / NORMAL
"ER;#U, ,Y,TEM A"DME"TAL C#"DITI#" ABNORMAL
A. SISTEM MUSKULOSKELETAL / NORMAL
MU,CUL#,?ELETAL ,Y,TEM ABNORMAL
%B. LAIN9LAIN / OTERS !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
BAHA!IAN ?
PART B
%% PEMERIKSAAN AIR KENCIN! / E&AMINATION OF URINE
!ULA ALBUMIN MICROSCOP1 !!!!!!!!!!!!!!!!!!
,UAR
BAHA!IAN @
PART C
PEN!ESAHAN DOKTOR / Certifi(+tion ,6 Do(tor
Sil tndkn . di dl% kotk 6n2 0e$kenn( Plea'e tic( ) in the appropriate bo+!
S6 %en2eshkn 0h& #d h$i ini s6 telh %e%e$iks 0 I certi-y that I ha*e thi' day ea+mined
AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA No( K'P I/C No. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
dn %end#ti 0h& 3
and -o/nd 3
Beliu tidk %en2hid# #9# #en6kit dn dishkn siht(
The abo*e named i' in 2ood health!
Beliu %en2hid# !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
The abo*e named ha'
Beliu sedn2 %end#t $&tn !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
The abo*e named i' /nder2oin2 treatment
Tndtn2n Dokto$ !!!!!!!!!!!!!!!!!!!!!!
,i2nat/re o- Doctor
N% Dokto$ AAAAAAAAAAAAAAAAAAAAAAAAAAA
TARIKH 3 !!!!!!!!!!!!!!!! "ame o- Doctor
DATE 3 Kelulusn dn Co# Rs%i Klinik !!!!!!!!!!!
D/ali-ication and o--icial 'tamp o- clinic