HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS

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Transcription:

HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS 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 4 SECTIONS: a) SECTION 1 (PART A AND B) TO BE FILLED BY THE APPLICANT; AND b) SECTION 2,3 AND 4 TO BE FILLED BY THE EXAMINING DOCTOR 5. PLEASE COMPLETE THE ENTIRE TEST REQUIRED IN THIS FORM. 6. THE UNIVERSITY / COLLEGE ONLY ACCEPT MEDICAL EXAMINATION DONE WITHIN 90 DAYS BEFORE ARRIVAL IN MALAYSIA. 7. PLEASE ATTACH ALL THE ORIGINAL LABORATORY RESULTS. 8. PLEASE BRING ALONG CHEST X-RAY FILM (OR DIGITAL IMAGES) AND REPORT FOR REGISTRATION, FOR THE PURPOSE OF VERIFICATION, IF NECESSARY. 9. PLEASE ENSURE THE X-RAY FILMS OR DIGITAL IMAGES ARE 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 SHOULD THERE BE ANY DOUBT IN THE MEDICAL REPORT SUBMITTED, ALL COSTS INVOLVED SHALL BE BORNE BY THE CANDIDATES. 12. THE UNIVERSITY / COLLEGE RESERVES THE RIGHT TO REJECT ANY APPLICATION: a) BASED ON THE RESULTS OF THE HEALTH EXAMINATION; OR b) SHOULD THERE BE ANY EVIDENCE THAT THE APPLICANT HAS GIVEN FALSE INFORMATION IN THE HEALTH EXAMINATION REPORT OR ANY SUPPORTING DOCUMENTS.

SECTION 1 (PART A) BLOOD GROUP (RHESUS) NATIONALITY CONTACT NUMBER IN MALAYSIA DATE OF BIRTH AGE SEX MARITAL STATUS ACADEMIC YEAR STUDENT ID PROGRAMME OF STUDY PROGRAMME CODE NEXT OF KIN NEXT OF KIN S ADDRESS NEXT OF KIN S CONTACT NUMBER The details of the blood type recorded here are as reported by the patient and have not been tested or verified to be correct by the medical practitioner completing this online medical screening questionnaire. The medical practitioner completing this form disclaims any and all liability to the fullest extent permitted by law for any personal injury, suffering or loss caused by any reliance on this information by any other party.

SECTION 1 (PART B) Declaration of self and family illness. Explain in full if you or your immediate* family has any of the following illnesses. * Immediate family refers to mother, brothers / sisters. MEDICAL PROBLEMS 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. History of Surgery 13. Tuberculosis (TB) 14. HIV / AIDS 15. Hepatitis B 16. Sexually Transmitted Diseases 17. Drug Addiction 18. Other Illnesses IMMEDIATE SELF FAMILY Yes No Yes No If Yes please state details Current medication (Long Term) VACCINATION HISTORY (where applicable) 1. Yellow Fever 2. BCG 3. Meningitis (Quadrivalent) 4. Hepatitis B 5. Polio 6. Measles 7. Rubella 8. Others: (specify) Yes No Date of Vaccination Notes : 1. *A valid Yellow Fever vaccination certificate is required from all travellers coming from or transited more than 12 hours through countries with risk of Yellow Fever transmission. 2. All students are required to take vaccines as listed in numbers 2-7 above. 3. The students are required to bring along the International Certificate of Vaccination or Prophylaxis with them for verification of information.

SECTION 2 - PHYSICAL EXAMINATION TYPE OF APPLICATION DATE OF MEDICAL SCREENING 1. BASIC MEASUREMENT HEIGHT (m) : WEIGHT (kg) BMI(kg/m²) PULSE RATE (PER MINUTE) SYSTOLIC (mmhg) BLOOD PRESSURE: DIASTOLIC (mmhg) VISION TEST NORMAL DEFECTIVE UNAIDED (L) UNAIDED (R) AIDED (L) AIDED (R) COLOR VISION TEST HEARING ABILITY NORMAL DEFECTIVE LEFT RIGHT 2. GENERAL EXAMINATION ITEM YES / ABNORMAL NO / NORMAL a. DEFORMITIES b. PALLOR c. CYANOSIS d. JAUNDICE e. OEDEMA f. SKIN DISEASES 3. SYSTEMIC EXAMINATION ITEM g. EYES (including funduscopy) h. EARS i. NOSE j. ORAL CAVITY / THROAT k. NECK l. CARDIOVASCULAR SYSTEM m. RESPIRATORY SYSTEM n. ABDOMEN/HERNIAL ORIFICES o. NERVOUS SYSTEM p. MENTAL STATUS q. MUSCULOSKELETAL SYSTEM NORMAL ABNORMAL

SECTION 2A - PHYSICAL EXAMINATION - EBOLA TYPE OF APPLICATION DATE OF MEDICAL SCREENING Have you in the last 30 days travelled to or from the following Ebola affected countries: ITEM YES NO Guinea Sierra Leone Liberia Nigeria Others (please specify) Have you in the last 30 days come into contact with someone, who has in the last 30 days, traveled to or from the following Ebola affected countries: ITEM YES NO Guinea Sierra Leone Liberia Nigeria Others (please specify) Have you in the last 30 days come into contact with Ebola infected persons or animals? ITEM YES NO YES/NO Do you have any of the following Ebola virus symptoms? ITEM YES NO Sudden onset of fever Intense weakness Myalgia Headache Sore Throat Vomiting Diarrhoea Rashes Haematuria Bloody Stool Internal or external bleeding Others (please specify)

SECTION 3 - LABORATORY RESULTS DATE OF LAB TEST NAME OF LAB URINE TEST ITEM POSITIVE / ABNORMAL NEGATIVE / NORMAL a. ALBUMIN b. SUGAR c. MICROSCOPIC EXAMINATION d. OPIATES (INCLUDING CODEINE, MORPHINE, HEROIN) e. CANNABINOIDS f. AMPHETAMINE TYPE STIMULANT BLOOD TEST ITEM POSITIVE / ABNORMAL NEGATIVE / NORMAL a. HEPATITIS Bs ANTIGEN c. HIV d. VDRL d. TPHA e. MALARIAL PARASITES * TPHA is done if VDRL is reactive ** all test results / reports is valid for 6 months

SECTION 4 - CHEST X-RAY FINDINGS DATE OF CHEST X-RAY PLACE OF CHEST X-RAY CHEST X-RAY NO. ITEM NORMAL THORACIC CAGE HEART SHAPE AND SIZE CTR IF APPLICABLE) LUNG FIELDS MEDIASTHNUM AND HILA PLEURA / HEMIDIAPHRAGMS / COSTOPHRENIC ANGLES FOCAL LESION ANY OTHER ABNORMALITIES IMPRESSION

SECTION 5 - CERTIFICATION BY THE EXAMINING DOCTOR TYPE OF APPLICATION DATE OF CERTIFICATION ITEM ABNORMAL HIV HEPATITIS B TUBERCULOSIS MALARIA TYPHOID SEXUALLY TRANSMITTED DISEASES PSYCHIATRIC DISORDERS EPILEPSY HIS/HER URINE FOR AMPHETAMINE TYPE STIMULANTS (ATS) (SCREENING TEST) HIS/HER URINE FOR OPEATES (SCREEENING TEST) HIS/HER URINE FOR CANNABINOIDS (SCREENING TEST) OTHERS (PLEASE SPECIFY UNDER S) HEREBY THE STUDENT IS CERTIFIED AS SUITABLE UNSUITABLE FOR STUDY IN MALAYSIA. NAME OF EXAMINING DOCTOR QUALIFICATION OF EXAMINING DOCTOR HOSPITAL/CLINIC REGISTRATION NUMBER

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