HEALTH EXAMINATION REPORT FOR INTERNATIONAL STUDENTS ‘SECTION 1 (PART B) Declaration of self and family illness. Explain in full if you or your immediate" family has any of the following illnesses. * Immediate family refers to mother, brothers / sisters. IMMEDIATE SELF MEDICAL PROBLEMS Aes If "Yes" please state details Yes Yes z & Congenital or inherited Disorder Allergy Mental liness: Fis, Stroke, Other Neurological Disease Diabetes Metitus Hypertension Hear or Vascular Disease Asthma ‘Thyroid Disease 10. Kidney Disease 11. Cancer 12. History of Surgery 13, Tuberculosis (TB) 14, HIV AIDS, 15. Hepatitis B 16. Sexually Transmitted Diseases 17. Drug Addiction, 18. Other ilinesses BONS \S\ANVINGVAMS ND VE da. AVA NN s Current medication (Long Term) IV VACCINATION HISTORY (where applicable) 1. Yellow Fever Bcc Meningitis (Quadrivalent) Pa a = Hepatitis B = 6 ap I eae Polio all ‘ oz TC Yes No Date of Vaccination Complet Vactina pin Measles Rubella Others: (specify) 1."A valid Yew Fever vaccination cetiicate is requred rom al raves coming io ‘of Yolow Fever tansmission Ter 2. Al students are required to tke vaccines as Hsted in rumbers 27 above, 2°. 3. The scents are required to bring along the International Cette of Vaccination of EDUCATION MALAYSIA GLOBAL SERVICES (986610-U) Education Malaysia One-Stop-Centre, 20th Floor, Menara TA One, 2, Jalan P-Ramlee, 50250 Kuala Lumpur, Malaysia “Tel: +603 2782 5888 Fax: +603 2711 8533 Portal: www.educationmalaysia gov.my