Documente Academic
Documente Profesional
Documente Cultură
UMS/PPPS/01
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
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HEALTH EXAMINATION * TO BE COMPLETED BY THE MEDICAL OFFICER PHYSICAL CONDITION Height Weight Pulse Blood Pressure cm kg /min
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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Heart Disease
Diabetes
Kidney Disease
Fits
Mental Illness
Cancer
2.
.................................. Date
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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)
Not in good health and is advised to seek medical treatment before registering in Universiti Malaysia Sabah
.................................. Date
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