KEJUARAAN SILAT OLAHRAGA MRSM ZON TIMUR 2018

HEALTH REPORT

Name: __________________________________________________ IC/Passport No.: _______________

CONFIRMATION OF SELF HELTHINESS * Thick ( / ) the
appropriate box.
Have you ever experienced of being treat for any of these illnesses:

Illness Yes No

1. Asthma

2. Heart Illness

3. High Blood Pressure

4. Diabetes

5. Fit

6. Handicapped

PARTICIPANT’S CONFIRMATION

I am_____________________________________________, IC/Passport No. _______________________,

here with confirm that all of the above is true.

______________ ________________________
Date Participant’s Signature in front of Doctor

DOKTOR’S CHECK-UP
1. Brain Condition 2. Pulse:
Normal Abnormal

3. Blood Pressure 4. Heart:

 Sistolik (mmhg)

Diastolik (mmhg)

5. Lung:
6. Abdomen:
Notes: ___________________________________________________________________________ I here with
confirm that this person:
Does not have any illness, healthy and allowed to join the tournament.

Have illness / illnesses of _____________________________________and allowed/

disallowed to join the tournament.

Date: ______________ __________________________

(Doctor’s Approval)
Doctor’s Name :