MEDICAL EXAMINATION FOR TEACHING PERMIT

* The candidate must complete Section A of the form and submit it to the Medical Officer at the time of
examination.
NAME ZALIPAH BINTI DOLLAH
(in block letters and in full)

NRIC NO 7400629-01-6012

DATE OF BIRTH 29 JUN 1974 AGE : 44 YRS OLD

GENDER MALE ( ) FEMALE (/)

MARTIAL STATUS SINGLE (/ ) MARRIED ( )
WIDOWED ( ) DIVORCED ( )
NO. 112, LRG SRI PERMAI,
PRESENT ADDRESS
JLN PT SEMERAH,

POSTCODE: 82000 TOWN: PONTIAN

STATE: JOHOR COUNTRY: MALAYSIA
NO. 112, LRG SRI PERMAI,
PERMANENT ADDRESS
JLN PT SEMERAH,

POSTCODE: 82000 TOWN: PONTIAN

STATE: JOHOR COUNTRY: MALAYSIA

TEL. NO. (HOME/MOBILE) 019-7575601 011-10752003

If yes, please provide

A. Candidate's declaration
dates and details:
1. Have you ever had or been told you had or been treated for : YES NO

(a) An operation?
 
(b) An accident needing hospital treatment?
 
(c) Any disease of the lung or respiratory problem
e.g. asthma, tuberculosis, bronchitis, pneumonia or  
abnormal chest x-ray?
(d) Any disease of the brain or nervous system
e.g. fits, epilepsy, seizure, fainting spells, nervous complaint  
or mental disorder or other psychiatric illnesses?

(e) Any disease of the cardiovascular system

e.g. coronary artery disease, hypertension, heart attack,  
stroke, chest pain, palpitations, loss of consciousness?

(f) Any disease of the digestive system

e.g. ulcer, disease of liver, stomach or intestine, gallbladder,  
jaundice, Hepatitis 8 or been a hepatitis carrier?

(g) Any disease of the spine, bone, joint , prolapsed

intervertebral disc, muscle, connective tissue, arthritis, gout  
or abnormality of the thyroid or endocrine glands including
goitre, lymph nodes or any disease of the skin?
 (h) Any diseases of the eyes, ears, nose or throat?
 
(i) Any cancer, tumour, cyst or any growth? Any venereal
diseases e.g. gonorrhoea, syphilis, chancre or other sores  
including genital sores or discharges?
(j) Any tropical diseases e.g. malaria or dysentery?
 
(k) Any other illness, disease, disorder or disability that has not
been mentioned above?  
2. Have your spouse, parents, brothers or sisters ever had or is now
subject to heart disease, stroke, cancer, diabetes, hypertension,  
kidney disease, tuberculosis, epilepsy, blood disorder, mental
disorder, fits or any other hereditary diseases?

3. Have you any physical infirmity, defects, deformities or health

impairments?  
4. Have you ever used habit forming drugs or narcotics, or been treated
for alcoholism or drug habit?  
5. Have you or your spouse ever received any medical advice,
counselling or treatment in connection with AIDS, AIDS Related  
Complex or any other AIDS related condition?
6. In the case of a female :
(a) Are you now pregnant? If so, how many months?
 
(b) Have you ever had any disease of the breast, female organs or
complications at child-birth?  
* Note: If you wear glasses for any purpose, you should take them with you for inspection by the Medical Officer.

DECLARATION & CONSENT

I the undersigned, hereby confirm that the information given above is complete, accurate and true. I understand
that the information provided by me and other details in the College records may be released to government,
legislative and enforcement agencies and where these information is required to comply with any laws or
regulatory requirements.

I hereby further authorise any physician, hospital, clinic, insurance company or other organisation, institution or
person, that has any records or knowledge of me or my health, to disclose to the College or its representative any
and all information about me with reference to my health and medical history and any hospitalisation, advice,
treatment, disease or ailment. A photostat copy of this authorisation shall be as effective and valid as the original.

Date: Signature:
B Examining Medical Officers are requested to make a thorough examination of the
candidate and to complete the report below:
1 (a) Have you attended to the candidate medically before?

(b) Height

(c) Weight

2 General condition/pallor

3 EYES
(a) Vision (uncorrected) R:

(b) Vision (corrected with glasses) L: R:

(c) Fundus examination (if possible)

4 EARS
(a) Presence of discharge

(b) Condition of drum

(c) Acuity of hearing

5 THROAT

6 CONDITION OF HEART
(a) Rhythm
(b) Character of impulse at apex beat

(c) Position of apex beat

(d) Any alteration of size?

(e) Any murmurs present?

7 PULSE
(a) Rate
(b) Character

(c) Any evidence of arterial changes

8 BLOOD PRESSURE
(a) Rate (Mercurial manometer readings preferred)
9 (a) IS THERE ANY ENLARGEMENT OF
(i) Liver?

(ii) Spleen?

(b) Any abnormal swelling in the abdomen?

10 URINE
(a) Specific Gravity
(b) Albumin Content

(c) Sugar Content

(d) Acetone Content

(e) Microscopical examination (if necessary)

11 NERVOUS SYSTEM
(a) Condition of patellar reflexes

(b) Condition of ankle reflexes

(c) Condition of planter reflexes

(d) Are pupils equal?

(e) Do the pupils react to light?

(f) Do the pupils react to accommodation?

(g) Any sensory loss?

12 HERNICAL ORIFICES

13 Any further examination which the examining officer considers it

necessary to conduct.

I hereby certify that I have examined :

Fu II Name: NRIC No.:

and that I find him/her free from any organic disease and is *medically fit/unfit for employment as a
teaching staff.

Any other Comments :

Signature :

Name of Medical Officer/Medical Practitioner :

Qualification:

Date: Official Chop: