PANDUAN PENDAFTARAN PELAJAR BAHARU PASCASISWAZAH

UMS/PPPS/01

STUDENT MEDICAL EXAMINATION FORM

PERSONAL INFORMATION * TO BE COMPLETED BY THE STUDENT Name (Capital Letter) Passport / ID No. Offered to School Programme of Study Permanent Address Home Telephone No. Gender Religion Place of Birth (as stated in Birth Cert.) FAMILY INFORMATION * TO BE COMPLETED BY THE STUDENT Father/Guardians Name (Capital Letter) Passport / ID No. Postal Address Telephone No. Name of Next of Kin Occupation Postal Address Telephone No. : : : : : : : Relationship : Occupation : : : : : : : : : : : Mobile No. : : : :

Male

Female

Race Birth of Date Age

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PANDUAN PENDAFTARAN PELAJAR BAHARU PASCASISWAZAH

HEALTH EXAMINATION * TO BE COMPLETED BY THE MEDICAL OFFICER PHYSICAL CONDITION Height Weight Pulse Blood Pressure cm kg /min

Please tick () in the appropriate box

Skin Lung Heart Abdomen Teeth Ear Nervous System Musculoskeletal System

Normal

Abnormal

EYE TEST Without Glassess/Contact Lenses With Glassess/Contact Lenses Colour Blind

Normal

Abnormal

URINE TEST (Please tick () in the appropriate box) Urine Sugar Albumin Blood/RBC Drugs Pregnancy

Yes

No

X-Ray Report (Not Necessary unless requested by examining Medical Officer) X-Ray No. X-Ray Report :

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PANDUAN PENDAFTARAN PELAJAR BAHARU PASCASISWAZAH

STUDENT HEALTH DECLARATION (WITNESSED BY THE DOCTOR)

Please tick () in the appropriate box. 1. DISEASES Have you ever been treated / diagnosed with the following diseases? Yes Asthma No Tuberculosis Yes No

Heart Disease

High blood pressure

Diabetes

Kidney Disease

Fits

Mental Illness

Cancer

Chronic Skin Disease

Allergy to Medicine/Food If other chronic disease YES, please state :

Other chronic Disease

2.

STUDENT DECLARATION* I, ............................................................................... ID / Passport No...............................

(Name as stated in the ID / Passport)

do hereby declared that all information stated is true.

.................................................. (Student Signature)

*To be signed witnessed by the Doctor

.................................. Date

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PANDUAN PENDAFTARAN PELAJAR BAHARU PASCASISWAZAH

3.

MEDICAL OFFICER DECLARATION (Please tick () in the approapriate box) I, .......................................................................................................................................... (Doctors name as stated in the Identification Card)

holder of Identification Card No................................................declare that I already examined the student and hereby testify that the student ...................................................................................... (Name of student as stated in the Identification Card)

He / She is in good health, dont have any diseases and fit to study in Universiti Malaysia Sabah.

Diagnosed with disease (s) which does not required long term treatment and fit to study in Universiti Malaysia Sabah. (Please state disease(s)

Disease: ............................................ Treatment: ..........................................

Not in good health and is advised to seek medical treatment before registering in Universiti Malaysia Sabah

..................................................................... (Doctors Signature & Official Stamp)

.................................. Date

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