Documente Academic
Documente Profesional
Documente Cultură
1.
2.
(b)
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.
5.
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:
Rev No. : 0
Page No: 1 of 5
Passport size
photo
Rev No. : 0
Page No: 2 of 5
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
1. Congenital or inherited disorder
SELF
Yes
No
IMMEDIATE
FAMILY*
Yes
No
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
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
Rev No. : 0
Page No: 3 of 5
WEIGHT : _____________ kg
:( R )
( L ) ____
( L ) ____
NORMAL
/ ABNORMAL*
* Additional comment:
_____________________________________
2. GENERAL EXAMINATION
ITEM
YES
NO
COMMENT
a. DEFORMITIES
b. JAUNDICE
c. OEDEMA
d. SKIN DISEASES
3. SYSTEM EXAMINATION
ITEM
NORMAL
ABNORMAL
a. EYES(including funduscopy)
b. EARS
c. NOSE
d. ORAL CAVITY / THROAT
e. NECK
f. HEART
g. LUNGS
h. ABDOMEN
i. NERVOUS SYSTEM
j. MENTAL CONDITION
k. MUSCULOSKELETAL SYSTEM
COMMENT
Rev No. : 0
Page No: 4 of 5
SECTION 3 - INVESTIGATION
URINE TEST
ITEM
DATE TAKEN
RESULT
a. ALBUMIN
b. SUGAR
c. MICROSCOPIC
REPORT
Rev No. : 0
Page No: 5 of 5
Date : _______________________
Signature of Doctor
Name of Doctor
Address of
Hospital/Clinic
Official stamp