BorangRME/ IPT Malaysia/HELP

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GUIDELINES
TO FILLIN HEALTHEXAMINATION
REPORT

1. PLEASEREADTHE INSTRUCTIONS
CAREFULLY
BEFOREFILLINGIN THE FORM.

2. PLEASEFILLIN THE FORMIN ENGLISH

LANGUAGE.

3. PLEASEWRITEIN CAPITALLETTERS.

4. THISFORMHAS2 SECTIONS

SECTION1 (PARTA AND B) TO BE FILLEDBY THE CANDIDATES

SECTION2 TO BE FILLEDBY THE EXAMINING

DOCTOR

5. PLEASECOMPLETE
ALL THETESTSREQUIRED
IN THISFORM.

6. PLEASEATTACHALLTHEORIGINALLABORATORY
RESULTS.

. 7. PLEASEBRINGALONGTHE CHESTX-RAYFILMAND REPORT.

A PLEASEENSURETHE X-RAYFILMIS LABELLED

WITHYOURNAMEAND DATE

TAKEN(tN ENGLTSH)

b CHESTX-RAYMUSTBE DONEWITHIN3 MONTHSPRIORTO REGISTRATION

8. UNIVERSITY
ONLYACCEPTMEDICALEXAMINATION
DONEWITHIN3 MONTH

BEFOREREGISTERATION.

9. UNIVERSITY
CONCERNED
HASTHE RIGHTTO REPEATTHE MEDICAL
CHECK-UP

SHOULDTHEREBE ANY DOUBTOF THE MEDICALREPORT.ALL COSTSINVOLVED

WILLBE PAIDBY THECANDIDATES.

 BorangRME/ IPT Malaysia/HELP

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t h e u n i v e r s i t yo f a c h i e v e r s
HELP UNIVERSITYCOLLEGE

REPORT
HEALTHEXAMINATION
ffi
PLEASEUSE CAPITALLETTERS

SECTION1 (To be completedby candidate)

(PART A)

FULL NArrE (AS !N PASSPORT)

COI.ITACTNUMBER

DATEOF BIRTH MARITALSTATUS

m MALE
FEMALE
SINGLE
MARRIED

INTAKE:YYYY-MM

FACULTY

NEXTOF KIN'SADDRESS

NEXT OF KIN'S COI{TACT NUMBER

SECTION1
(PARTB) - Plcasctick ( { ) in the rclevantbox.

Dcclarationof sclf and family illness.Explain in full if you or your family hasany of thc following illncsscs.
* Immediate family refers to father, mother, brothers / sisters

IiIiIEDIATE
SELF
MEDIGALPROBLEMS FAilILY lf 'Yeg'plomc atttc.
Yes No Yes No
1. or inheriteddisorder
Congenital

2. Allergy
 BorangRME/ IPT Malaysia/HELP

3. Mentalillness

4. Fits,stroke,other neurologicaldisease

5. DiabetesMellitus

6. Hypertension

7. Heartor vasculardisease

8. Asthma

9. Thyroiddisease

10. Kidneydisease

11. Cancer

12. Tuberculosis

13. Drugaddiction

1 4 . A I D S ,H I V

15. History
of surgery
16. Otherillnesses

Currentmedication(Longterm)

I hcreby certify that the information given above is truc. I understandthat my application will be rejected if tnere is iny false lntonnatlon givcn

Date Signatureof candidate

SECTION2 . PHYSICALEXAMINATTON
To befilledby examining
doctor

I. BASICMEASUREMENT

HElcHr , -/8-3 ^ BLooD .4A./15fu'^^rn

PREssuRE
WEIGHT: PULSE
RArE ,lfi/r/ A ,^,^

l n

vlsroNrEsr : Unaided
,nl/lL g - 9.d- COLOURVISIONTEST :

Aided : (R)_--- (L) _ NORMAL / ABNORMAL

-

2. GEIiIERAI.

ITEM YES NO COi'MENT

a. DEFORMiTIES t/
b. PALLOR t/
 BorangRME/ IPT Malaysia/HELP

r GDBIA

g(NIDsEASES

a. EYES(includingfunduscopy)
4---

d. ORALCAVITY/THROAT

h- ABDOMEN/ HERNIAORIFICES

sEcTloN3 INVESTIGATIONS

URII.IETEST
rTEM DATETAt(Eil RESULT

a. ALBUMIN
/!,,v9 /t/tt q6' ,fuo;f-
. /

b. SUGAR
/!. Pq'tule 4.6 ,n,*rd'h
c. MICROSCOPIC
4&lft4
d. i,ORPHINE
4(/ / (ruwL2
e

I.
CA|INABTS

AIFIFAI|NES TYPE SIrlPUrI /

"7
ie.mrsr
ITEI DATE TAKEI{ RESULT

r. €r--S 3 A\-G€\

: 'iFr-S:
tr'Z
 BorangRME/ IPT Malaysia/HELP

X.RAYI}IFOnIIATFH
C+TEST

CHESTX.RAYNO.

SECTION4 . CERTIFICATIONBY THE EXAMININGDOCTOR

tick({) in theappropriate
Please box

PassportNo. andfoundhim/ her:-

W IN GOODHEALTH

T HAS MEDICALPROBLEM(PleaseState)

lS UNDERGOING
TREATMENTFOR:(PleaseState)

DateW Signatureof Doctor

Nameof Doctor

Qualificationand

Ofticialstampol Clinic

RemarksBy UniversityOtficial :
4EPITEPAI
KAPAAY
ME A OCM