KEMBARAN A KEPADA

MK MEDAN TD/G3/1/PKBM/362
BERTARIKH JAN 2015

BORANG PENGESAHAN KESIHATAN

PEMERIKSAAN KESIHATAN UNTUK:...........................................................................................................

No Kad Pengenalan:...................................................................................................................................

Nama:........................................................................................................................................................

Tarikh Lahir:...........................................................Unit Gabungan:...........................................................

Chest Measumment: Full Expiration:.........................................Unit:..................................................

Ear Test Right:..................................Left:........................................Both:.................................................

Eye Test Right:.................................Left:........................................(Without Glass)

Right:.................................Left:........................................(With Glass)

Colour Blind:............................................................................................................................................

B/P:..............................................mm HG Pulse:................................................................................

Height:.........................................m Weight:..................................kg BMI:............................................

Urine Test Sugar:...........................................Albumin:...........................................................................

Chest X-Ray Tarikh:.......................................Nombor:........................Keputusan:.................................

Keputusan FIT / UNFIT

Saya sahkan yang saya telah memeriksa (Nama) :.......................................................................

............................................................................................................dan didapati pemohon*

Layak/Tidak Layak untuk berkhidmat didalam Pasukan Kadet Bersatu Malaysia (PKBM) Darat.

Tempat :....................................... .........................................................................

Tandatangan Pegawai Perubatan

Nama:...............................................................

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