FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS

MALAYSIAN STUDENTS Applicable to full-time students only

1. All full-time students are required to undergo medical check-up at the recognized Government Hospitals/University Hospitals/Panel Clinics.

2. Please read the instructions carefully before filling in the form. 3. Please fill in the form in English Language. 4. Please write in CAPITAL LETTERS. 5. This form has five (5) sections:

a. part 1 and 2 to be filled by the student; and b. part 3, 4 and 5 to be filled by the examining medical officer only.

6. Please bring along chest x-ray film and report on the registration day. 7. Please ensure the x-ray film is labelled with your name and date taken. 8. Chest x-ray done within 6 months prior to registration can be accepted. 9. The university/college reserves the right to repeat full medical check-up or any specific

laboratory tests. All costs involved shall be borne by the student. 10. The university/college reserves the right to reject any application or cancel any registration:

a. based on the results of the health examination; or b. should there be any evidence that the student has given false information in the

health examination report or any supporting documents.

INTERNATIONAL STUDENTS

1. Please read the instructions carefully before filling in the form. 2. Please fill in the form in English Language. 3. Please write in CAPITAL LETTERS. 4. This form has four (4) sections:

a. section 1 (part a and b) to be filled by the student; and b. section 2, 3 and 4 to be filled by the examining doctor.

5. Please complete all the tests required in this form 6. The university/college only accepts medical examination done within 60 days before

registration or within 30 days after registration 7. Please attach all the ORIGINAL laboratory results 8. Please bring along chest x-ray film and report on the registration day. 9. Please ensure the x-ray film is labelled with your name and date taken (in english) 10. Chest x-ray done within 6 months prior to registration can be accepted 11. The university/college reserves the right to repeat full medical check-up or any specific

laboratory tests. All costs involved shall be borne by the student. 12. The university/college reserves the right to reject any application or cancel any registration:

a. based on the results of the health examination; or b. should there be any evidence that the student has given false information in the

health examination report or any supporting documents

IIUM HEALTH AND WELLNESS CENTRE INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA

Health examination guidelines

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INSTRUCTION: PLEASE FILL IN USING CAPITAL LETTERS SECTION 1 (To be completed by candidates) (PART A) FULL NAME (AS IN PASSPORT)

INTERNATIONAL PASSPORT NO.

NATIONALITY CONTACT NUMBER

DATE OF BIRTH AGE SEX MARITAL STATUS

MALE SINGLE

D D M M Y Y FEMALE MARRIED

ACADEMIC YEAR STUDENT ID

/

PROGRAMME OF STUDY PROGRAMME CODE

NEXT OF KIN

NEXT OF KIN’S ADDRESS

NEXT OF KIN’S CONTACT NUMBER .

HEALTH EXAMINATION REPORT (for International Students)

IIUM HEALTH AND WELLNESS CENTRE INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA

PASSPORT SIZE

PHOTO

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SECTION 1 (PART B) – Please tick ( √ ) in the relevant box Declaration of self and family illness. Explain in full if you or your family has any of the following illnesses. * Immediate family refers to father, mother, brothers / sisters

MEDICAL PROBLEMS SELF IMMEDIATE FAMILY If “Yes”

please state. Yes No Yes No

1 Congenital or inherited disorder

2 Allergy

3 Mental illness

4 Fits, stroke, other neurological disease

5 Diabetes Mellitus

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) ___________________________________ _________________________________ ___ ___________________________________ _____________________________________

IMMUNIZATION HISTORY (where applicable)

DATE IMMUNIZED

1 Yellow Fever

2 BCG

3 Meningitis (Quadrivalent)

4 Hepatitis B

5 Others:

I hereby certify that the information given above is true. I understand that my application/ registration will be rejected/cancelled if there is any false information given. ………………………….. …………………………………………….

Date Signature of candidate

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SECTION 2 - PHYSICAL EXAMINATION To be filled by examining doctor

1. BASIC MEASUREMENT

HEIGHT : __________________ m WEIGHT : __________________ kg

BLOOD PRESSURE : ______________ mmHg PULSE RATE : ______________ / min

VISION TEST : Unaided : (R) _______ (L) ________ COLOUR VISION TEST :

Aided : (R) _______ (L) ________ NORMAL / ABNORMAL

2. GENERAL EXAMINATION

ITEM YES NO COMMENT

a. DEFORMITIES

b. PALLOR

c. CYANOSIS

d. JAUNDICE

e. OEDEMA

f. SKIN DISEASES

3. SYSTEMIC EXAMINATION

ITEM NORMAL ABNORMAL COMMENT

a. EYES (including funduscopy)

b. EARS

c. NOSE

d. ORAL CAVITY / THROAT

e. NECK

f. HEART

g. LUNGS

h. ABDOMEN / HERNIA ORIFICES

i. NERVOUS SYSTEM

j. MENTAL CONDITION

k. MUSCULOSKELETAL SYSTEM

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SECTION 3 - INVESTIGATIONS

URINE TEST

ITEM DATE TAKEN RESULT

a. ALBUMIN

b. SUGAR

c. MICROSCOPIC

d. MORPHINE

e. CANNABIS

f. AMPHETAMINES TYPE STIMULANT

BLOOD TEST

ITEM DATE TAKEN RESULT

a. HEPATITIS Bs ANTIGEN

b. HEPATITIS C

c. HIV

d. VDRL / TPHA

e. MALARIAL PARASITE

CHEST X-RAY INFORMATION

CHEST X-RAY NO.

DATE TAKEN

PLACE TAKEN

REPORT

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SECTION 4 - CERTIFICATION BY THE EXAMINING DOCTOR Please tick (√) in the appropriate box : I certify that I have on this date ___________________________ examined

Mr / Ms ___________________________________________________________________

Passport No. __________________________________ and found him / her :-

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________ ……………………………………………………… ………………………………… Signature of Doctor Date Name of Doctor : ______________________________________________________

Qualification : ______________________________________________________

Hospital/Clinic : ______________________________________________________

Registration Number : ______________________________________________________

Official stamp :

IN GOOD HEALTH

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

UNDERGOING TREATMENT FOR: (Please State)

REMARKS BY UNIVERSITY OFFICIAL:

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(Part 1 and 2 are to be completed by students) (Part 3, 4 and 5 are to be filled by the Examining Medical Officer only)

INSTRUCTION: PLEASE FILL IN CAPITAL LETTERS / ARAHAN: SILA ISI DALAM HURUF BESAR

CANDIDATE’S

PASSPORT

PHOTOGRAPH /

GAMBAR PASPORT

CALON

MEDICAL CHECK-UP FORM (for Malaysian Students)

IIUM HEALTH AND WELLNESS CENTRE INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA

PART 1 / BAHAGIAN 1 ACADEMIC YEAR / TAHUN AKADEMIK PROGRAMME / PROGRAM SEMESTER

/ As in the Offer Letter / Seperti dalam Surat Tawaran

KULLIYYAH

MATRIC NO. / NO. MATRIK CONTACT NO. / NO. TELEFON

As in the Offer Letter / Seperti dalam Surat Tawaran

FULL NAME / NAMA PENUH

IDENTITY CARD / PASSPORT NO. / NO. KAD PENGENALAN / PASPORT AGE / UMUR

NATIONALITY / KEWARGANEGARAAN DATE OF BIRTH / TARIKH LAHIR

D D M M Y Y Y Y

MALE / LELAKI FEMALE / PEREMPUAN SINGLE / BUJANG MARRIED / BERKAHWIN

NAME OF GUARDIAN / NAMA PENJAGA

POSTAL ADDRESS OF GUARDIAN / ALAMAT PENJAGA

HOUSE TELEPHONE NO. / NO. TELEFON RUMAH OFFICE TELEPHONE NO. / NO. TELEFON PEJABAT

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PART 2 / BAHAGIAN 2 Please tick (/) in the relevant box / Sila tandakan (/) di kotak berkenaan

Declaration of self and immediate family (father, mother, siblings) illness. Explain in full if you or your family has

any of the following illnesses. / Pengakuan mengenai penyakit yang dihidapi sendiri dan ahli keluarga terdekat

(ibu, bapa, adik-beradik). Sila jelaskan dengan lanjut sekiranya anda atau ahli keluarga menghidapi penyakit-

penyakit berikut:

NO. MEDICAL PROBLEMS (Masalah Kesihatan)

SELF IMMEDIATE

FAMILY If Yes, please state

(Jika Ya, sila nyatakan) Yes No Yes No

1 Congenital or inherited disorder (Penyakit sejak lahir/ penyakit keturunan)

2 Allergy (Alergi)

3 Mental illness (Sakit jiwa)

4 Fits, stroke, other neurological disease (Sawan, strok dan lain-lain penyakit saraf)

5 Diabetes Mellitus (Kencing manis)

6 Hypertension (Darah tinggi)

7 Heart or vascular disease (Sakit jantung)

8 Asthma (Lelah)

9 Thyroid disease (Sakit tiroid)

10 Kidney disease (Sakit buah pinggang)

11 Cancer (Kanser)

12 Tuberculosis (Batuk kering)

13 Drug addiction (Penyalahgunaan dadah)

14 AIDS, HIV

15 Epilepsy (Gila babi)

16 Deformity (Kecacatan)

17 History of surgery (Sejarah pembedahan)

18 Other illnesses (Lain-lain penyakit)

I hereby certify that the information given above is true / Saya dengan ini mengaku segala maklumat kesihatan

yang diberi di atas adalah benar

………………………………………………………………….. …………………………………. Signature of candidate / Tandatangan calon Date / Tarikh

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PART 3 / BAHAGIAN 3 TO BE FILLED BY EXAMINING DOCTOR / UNTUK DIISI OLEH DOKTOR YANG MEMERIKSA

Tick as relevant / Tandakan yang berkaitan

1. GENERAL EXAMINATIONS / PEMERIKSAAN UMUM

HEIGHT / TINGGI cm/sm WEIGHT / BERAT kilogram

PULSE / NADI per minute / seminit BP / mmHg

a. PALLOR b. CYANOSIS c. OEDEMA

d. JAUNDICE e. LYMPH NODES f. SKIN

2. EXAMINATION OF EYE / RIGHT / LEFT / REMARKS / PEMERIKSAAN MATA KANAN KIRI CATATAN

a. UNAIDED VISION / PENGLIHATAN TANPA KACA MATA

__________________

b. AIDED VISION / PENGLIHATAN DENGAN KACA MATA

__________________

c. FUNDOSCOPY NORMAL

ABNORMAL __________________

d. COLOUR VISION / PENGLIHATAN WARNA

NORMAL

__________________ ABNORMAL

3.

EXAMINATION OF EAR / PEMERIKSAAN TELINGA

NORMAL

__________________ ABNORMAL

4.

ORAL CAVITY / RUANG MULUT

NORMAL

__________________ ABNORMAL

5.

HEART / JANTUNG

NORMAL

__________________ ABNORMAL

/

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6.

a. RESPIRATORY SYSTEM / SISTEM RESPIRATORI

NORMAL

__________________ ABNORMAL

b. * X-RAY NORMAL

__________________ ABNORMAL

* PLEASE ATTACH CHEST X-RAY AND REPORT (large film) / * LAMPIRKAN X-RAY DADA SERTA LAPORAN (filem besar) DATE OF X-RAY TAKEN / PLACE TAKEN / X-RAY REF. NO. TARIKH X-RAY DIAMBIL TEMPAT DIAMBIL NO. RUJUKAN X-RAY

D D M M Y Y

7.

ABDOMEN & HERNIAL ORIFICES / ABDOMEN & RONGGA HERNIA

NORMAL

__________________ ABNORMAL

8.

NERVOUS SYSTEM AND MENTAL CONDITION / SISTEM SARAF DAN MENTAL

NORMAL

__________________ ABNORMAL

9.

MUSCULOSKELETAL SYSTEM / SISTEM MUSKULOSKELETAL

NORMAL

__________________ ABNORMAL

10. OTHERS / LAIN-LAIN ________________________________________________________________

PART 4 / BAHAGIAN 4 11. EXAMINATION OF URINE / PEMERIKSAAN AIR KENCING Sugar / Gula _____________ Albumin ____________ Microscopy ____________

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PART 5 / BAHAGIAN 5 CERTIFICATION BY DOCTOR / PENGESAHAN DOKTOR Please tick (/) in the appropriate box / Sila tandakan (/) di alam kotak yang berkenaan I certify that on this day I have examined / Saya mengesahkan bahawa pada hari ini saya telah memeriksa

__________________________________________________I.C. No. / No. K.P. ________________________

and found that : / dan mendapati bahawa :

The above named is in good health / Beliau tidak menghidapi apa-apa penyakit dan disahkan sihat

The above named has / Beliau menghidapi ______________________________________________

The above named is undergoing treatment / Beliau sedang mendapat rawatan ________________

_________________________________________________________________________________

Signature of Doctor : _______________________ Date / Tarikh : ______________ Tandatangan Doktor Name of Doctor : _____________________________________________________________ Nama Doktor Qualification / Official stamp of hospital / clinic : Kelulusan dan Cop Rasmi Klinik:

REMARKS BY UNIVERSITY OFFICIAL: