Professional Documents
Culture Documents
1. All full-time students are required to undergo medical check-up at the IIUM Health and
Wellness Centre as scheduled by the Health and Wellness Centre.
2. Please read the instructions carefully before filling in the form.
3. Please fill in the form in English Language.
4. Please write in CAPITAL LETTERS.
5. This form has five (5) sections:
a. part 1 and 2 to be filled by the student; and
b. part 3, 4 and 5 to be filled by IIUM Medical Officers.
6. Please bring along chest x-ray film and report during the medical check-up day.
7. Please ensure that the x-ray film is labeled with your name and date taken.
8. Chest x-ray done within 6 months prior to registration can be accepted.
9. The university reserves the right to perform any specific tests if required. All costs involved
shall be borne by the student.
10. The university reserves the right to reject any application or cancel any registration:
a. based on the results of the health examination; or
b. should there be any evidence that the student has given false information in the
health examination report or any supporting documents.
INTERNATIONAL STUDENTS
1. All students are required to undergo medical check-up at the IIUM Health and Wellness
Centre as scheduled by the Health and Wellness Centre.
2. Please read the instructions carefully before filling in the form.
3. Please fill in the form in English Language.
4. Please write in CAPITAL LETTERS.
5. This form has four (4) sections:
a. part 1 (part a and b) to be filled by the student; and
b. part 2, 3 and 4 to be filled by IIUM Medical Officers.
6. Chest x-ray will be performed at the IIUM Health and Wellness Centre.
7. The university reserves the right to perform any specific tests if required. All costs involved
shall be borne by the student.
8. The university reserves the right to reject any application or cancel any registration:
a. based on the results of the health examination; or
b. should there be any evidence that the student has given false information in the
health examination report or any supporting documents.
IIUM HEALTH AND WELLNESS CENTRE CANDIDATE’S
INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA PASSPORT
PHOTOGRAPH /
MEDICAL CHECK-UP FORM GAMBAR PASPORT
(for Malaysian Students) CALON
PART 1 / BAHAGIAN 1
IDENTITY CARD / PASSPORT NO. / NO. KAD PENGENALAN / PASPORT AGE / UMUR
D D M M Y Y Y Y
HOUSE TELEPHONE NO. / NO. TELEFON RUMAH OFFICE TELEPHONE NO. / NO. TELEFON PEJABAT
1
PART 2 / BAHAGIAN 2
Please tick (/) in the relevant box / Sila tandakan (/) di kotak berkenaan
Declaration of self and immediate family (father, mother, siblings) illness. Explain in full if you or your family has
any of the following illnesses. / Pengakuan mengenai penyakit yang dihidapi sendiri dan ahli keluarga terdekat
(ibu, bapa, adik-beradik). Sila jelaskan dengan lanjut sekiranya anda atau ahli keluarga menghidapi penyakit-
penyakit berikut:
IMMEDIATE
MEDICAL PROBLEMS SELF If Yes, please state
NO. FAMILY
(Masalah Kesihatan) (Jika Ya, sila nyatakan)
Yes No Yes No
1 Congenital or inherited disorder
(Penyakit sejak lahir/ penyakit keturunan)
2 Allergy (Alergi)
3 Mental illness (Sakit jiwa)
4 Fits, stroke, other neurological disease
(Sawan, strok dan lain-lain penyakit saraf)
5 Diabetes Mellitus (Kencing manis)
6 Hypertension (Darah tinggi)
7 Heart or vascular disease (Sakit jantung)
8 Asthma (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)
I hereby certify that the information given above is true / Saya dengan ini mengaku segala maklumat kesihatan
yang diberi di atas adalah benar
………………………………………………………………….. ………………………………….
Signature of candidate / Tandatangan calon Date / Tarikh
2
PART 3 / BAHAGIAN 3
TO BE FILLED BY EXAMINING DOCTOR / UNTUK DIISI OLEH DOKTOR YANG MEMERIKSA
Tick as relevant / Tandakan yang berkaitan /
a. UNAIDED VISION /
PENGLIHATAN TANPA KACA MATA __________________
b. AIDED VISION /
PENGLIHATAN DENGAN KACA MATA __________________
c. FUNDOSCOPY NORMAL
ABNORMAL __________________
5. HEART / NORMAL
JANTUNG ABNORMAL __________________
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6. a. RESPIRATORY SYSTEM / NORMAL
SISTEM RESPIRATORI ABNORMAL __________________
b. * X-RAY NORMAL
ABNORMAL __________________
D D M M Y Y
PART 4 / BAHAGIAN 4
4
PART 5 / BAHAGIAN 5
CERTIFICATION BY DOCTOR / PENGESAHAN DOKTOR
Please tick (/) in the appropriate box / Sila tandakan (/) di alam kotak yang berkenaan
I certify that on this day I have examined / Saya mengesahkan bahawa pada hari ini saya telah memeriksa
__________________________________________________I.C. No. / No. K.P. ________________________
and found that : / dan mendapati bahawa :
The above named is in good health / Beliau tidak menghidapi apa-apa penyakit dan disahkan sihat
The above named is undergoing treatment / Beliau sedang mendapat rawatan ________________
_________________________________________________________________________________