Health Examination Report

Health Examination Guidelines
For Entry Into

Universiti Tunku Abdul Rahman
1.
Read the instructions carefully before filling in the form.
2.
The form has 4 sections:
(1) Section 1 (Parts A and B) to be filled by the candidate; and

(2) Sections 2, 3 and 4 to be filled by the examining doctor. Please complete all the
tests required in this form.
3.
The university only accepts medical examination done within 60 days before
registration or within 30 days after registration.
4.
Attach all original laboratory result.
5.
Chest x-ray done within 6 months prior to registration can be accepted.
6.
Please keep the chest x-ray film for future verification, if required.
7.
The university reserves the right to request full medical check-up or any specific
laboratory tests should there be any doubt in the medical report submitted. All costs
involved shall be borne by the candidates.
8.
Before submission please make a photocopy of the Health Examination Report and
all documents pertaining to the Health Examination for your own reference.
9.
This page will be returned to you after it has been acknowledged receipt by a staff of
the University.
Students Name:
NRIC No.:
Students Signature:
Received By:
Staffs Name:
Department/Faculty:
Date Received:
UniversitiTunkuAbdulRahman
FormTitle:HEALTHEXAMINATIONREPORT
FormNumber:FMDACE014RevNo.:0
EffectiveDate:01/01/2011
PageNo:1of5
PLEASE USE CAPITAL LETTERS
Passportsize
photo
SECTION 1 (To be completed by candidate)

(PART A)
FULL NAME: _______________________________ REGISTRATION NO.: ________________

CONTACT NUMBER: ________________________ DATE OF BIRTH: ___________________
MARITAL STATUS: SINGLE* / MARRIED*
GENDER: MALE* / FEMALE*
PROGRAMME OF STUDY: __________________________________________________________

NEXT OF KIN : ____________________________________________________________________
NEXT OF KINS CONTACT NUMBER: _________________________________________________
NEXT OF KINS ADDRESS: _________________________________________________________
________________________________________________________________________________
* Delete whichever not applicable
PageNo:2of5
SECTION 1
(PART B) Please tick ( ) in the relevant box
Declaration of self and family illness. Explain in full if you or your family have any of the following
illnesses
* Immediate family refers to father, mother, brothers / sisters
MEDICAL PROBLEMS
SELF
Yes
IMMEDIATE
FAMILY*
No Yes
If Yes please specify
No
1. Congenital or inherited disorder

2. Allergy
3. Mental illness
4. Fits, stroke, other neurological disease
5. Diabetes
6. Hypertension
7. Heart or vascular disease
8. Asthma
9. Thyroid disease
10. Kidney disease
11. Cancer
12. Tuberculosis
13. drug addiction
14. AIDS, HIV
15. History of surgery
16. Other illnesses
Current medication (Long term) (If applicable)
I hereby certify that the information given above is true. I understand that my application will be
rejected if there is any false information given.
Date
Signature of Candidate
2
FormNumber:FMDACE014
RevNo.:0
PageNo:3of5
SECTION 2 PHYSICAL EXAMINATION

To be filled by examining doctor
1. BASIC MEASUREMENT
HEIGHT : _____________ m
BLOOD PRESSURE : ______________

mmHg
WEIGHT : _____________ kg
PULSE RATE : __________________ / min
VISION TEST: Unaided :( R )

Aided :( R )
( L ) ____
COLOUR VISION TEST (including Colour

Blindness) :
NORMAL / ABNORMAL*
( L ) ____
* Additional comment:
_____________________________________
2. GENERAL EXAMINATION
ITEM
YES
NO
COMMENT
a. DEFORMITIES
b. JAUNDICE
c. OEDEMA
d. SKIN DISEASES
3. SYSTEM EXAMINATION
ITEM
a. EYES(including funduscopy)
b. EARS
c. NOSE
d. ORAL CAVITY / THROAT
e. NECK
f. HEART
g. LUNGS
NORMAL
ABNORMAL
COMMENT
h. ABDOMEN
i. NERVOUS SYSTEM
j. MENTAL CONDITION
k. MUSCULOSKELETAL SYSTEM
FormNumber:FMDACE014
RevNo.:0
PageNo:4of5
SECTION 3 - INVESTIGATION
URINE TEST
ITEM
a. ALBUMIN
b. SUGAR
c. MICROSCOPIC
CHEST X-RAY INFORMATION

DATE TAKEN
PLACE TAKEN
REPORT
DATE TAKEN
RESULT
PageNo:5of5
SECTION 4 - CERTIFICATION BY THE EXAMINING DOCTOR

Please tick ( ) in the appropriate box
I certify that I have on this date _________________________________________________
examined Mr / Ms _________________________________ IC No._________________________
and found him / her:IN GOOD HEALTH AND FREE OF PSYCHOSIS
HAVING THE FOLLOWING MEDICAL COMPLICATION (S) (Please specify)
UNDERGOING TREATMENT FOR: (Please specify)
Date : _______________________
Signature of Doctor
Name of Doctor
Address of
Hospital/Clinic
Official stamp
RemarksbyUniversityOfficial:

Health Examination Report

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Health Examination Guidelines

For Entry Into

Read the instructions carefully before filling in the form.

The form has 4 sections:

(1) Section 1 (Parts A and B) to be filled by the candidate; and

Attach all original laboratory result.

Chest x-ray done within 6 months prior to registration can be accepted.

PLEASE USE CAPITAL LETTERS

SECTION 1 (To be completed by candidate)

FULL NAME: _______________________________ REGISTRATION NO.: ________________

GENDER: MALE* / FEMALE*

PROGRAMME OF STUDY: __________________________________________________________

If Yes please specify

1. Congenital or inherited disorder

SECTION 2 PHYSICAL EXAMINATION

BLOOD PRESSURE : ______________

PULSE RATE : __________________ / min

VISION TEST: Unaided :( R )

COLOUR VISION TEST (including Colour

CHEST X-RAY INFORMATION

SECTION 4 - CERTIFICATION BY THE EXAMINING DOCTOR

HAVING THE FOLLOWING MEDICAL COMPLICATION (S) (Please specify)

UNDERGOING TREATMENT FOR: (Please specify)

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FULL NAME: _______________ REGISTRATION NO.: