HEALTH EXAMINATION GUIDELINES FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS

1. 2. 3. 4. PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE FILLING IN THE FORM. PLEASE FILL IN THE FORM IN ENGLISH LANGUAGE. PLEASE WRITE IN CAPITAL LETTERS. THIS FORM HAS 4 SECTIONS: (A) SECTION1 (PART A AND B) TO BE FILLED BY THE CANDIDATE; AND (B) SECTION 2 3 AND 4 TO BE FILLED BY THE EXAMINING DOCTOR !. #. PLEASE COMPLETE ALL THE TESTS RE"UIRED IN THIS FORM. THE UNI$ERSITY % COLLEGE ONLY ACCEPT MEDICAL EXAMINATION DONE WITHIN #& DAYS BEFORE REGISTRATION OR WITHIN 3& DAYS AFTER REGISTRATION. '. (. *. 1&. 11. PLEASE ATTACH ALL THE ORIGINAL LABORATORY RESULTS. PLEASE BRING ALONG CHEST X)RAY FILM AND REPORT FOR REGISTRATION. PLEASE ENSURE THE X)RAY FILM IS LABELED WITH YOUR NAME AND DATE TA+EN (IN ENGLISH). CHEST X)RAY DONE WITHIN # MONTHS PRIOR TO REGISTRATION CAN BE ACCEPTED. THE UNI$ERSITY % COLLEGE RESER$ES THE RIGHT TO REPEAT FULL MEDICAL CHEC+)UP OR ANY SPECIFIC LABORATORY TESTS SHOULD THERE BE ANY DOUBT IN THE MEDICAL PORTS SUBMITTED. ALL COSTS IN$OL$ED SHALL BE BORNE BY THE CANDIDATES. 12. THE UNI$ERSITY % COLLEGE RESER$E THE RIGHT TO RE,ECT ANY APPLICATION: (A) BASED ON THE RESULTS OF THE HEALTH DOMINATION; OR (B) SHOULD THERE BE ANY E$IDENCE THAT THE APPLICANT AS GI$EN FALSE INFORMATION THE HEALTH EXAMINATION REPORT OR ANY SUPPORTING DOCUMENTS.

THE OTOMOTIF COLLEGE MALAYSIA HEALTH EXAMINATION REPORT FOR LOCAL STUDENT
PLEASE USE CAPITAL LETTERS

Passport size photo

SECTION 1 (-. /0 1.2340-05 /6 1785957-0)

(PART A) FULL NAME (7: 98 37::3.;-)

NRIC NO.

NATIONALITY

CONTACT NUMBER

DATE OF BIRTH STATUS D D M M Y Y

AGE

SEX MALE FEMAL E STUDENT ID

MARTIAL SINGLE MARRIE D

ACADEMIC YEAR / PROGRAMME OF STUDY

PROGRAMME CODE

NEXT OF KIN

NEXT OF KINS ADDRESS

NEXT OF KINS CONTACT NUMBER

SECTION 1

(PART B) Please tick !" i# the rele$a#t %o& Declaratio# o' sel' a#( 'a)il* ill#ess+ PLEASE e&plai# i# ',ll i' *o, or *o,r 'a)il* has a#* o' the 'ollo-i#. ill#ess/ 0 I))e(iatel* 'a)il* re'ers to 'ather+ )other+ %rothers/sisters/
SEL F Yes N% IMMEDIA TE FAMILY Yes N%

MEDICAL PROBLEMS

If yes

!"e#se s$#$e

1/ 1o#.e#ital or i#herite( (isor(er 2/ Aller.* 2/ Me#tal ill#ess 3/ Epileps*+ stroke+ other #e,rolo.ic (isease 4/ Dia%etes )ellit,s 5/ 6*perte#sio# 7/ 1ar(io$asc,lar (isease 8/ Asth)a 9/ :h*roi( (isor(ers 1;/ <i(#e* (isease 11/ 1a#cer 12/ :,%erc,losis 12/ Dr,. a((ictio# 13/ AIDS+ 6I= 14/ 6istor* o' s,r.er* 15/ >ther ill#esses

1,rre#t )e(icatio# Lo#. ter)"

IMMUNI&ATION HISTORY ('(e)e #!!"*+#,"e) 1/ Yello- Fe$er 2/ ?1G 2/ Me#i#.itis @,a(ri$ale#t" 3/ 6epatitis ? 4/ >thersA

DATE IMMUNI&ATION

I here%* certi'* that the i#'or)atio# .i$e# a%o$e is tr,e/ I ,#(ersta#( that )* applicatio# -ill %e reBecte( i' there is a#* 'alse i#'or)atio# .i$e#/

Date

Si.#at,re o' ca#(i(ate

SECTION - . PHYSICAL EXAMINATION

:o %e 'ille( %* e&a)i#i#. (octor
1/ BASIC MEASUREMENT 6EIG6: A DEIG6:A =ISI>N :ES: A C#ai(e( A Ai(e( A R" R" L" L" ) ?L>>D PRESSCRE A PCLSE RE:E A ))6. / )i#

1>L>CR =ISI>N :ES: A N>RMAL / A?N>RMAL

-/ GENERAL EXAMINATION ITE M a/ DEF>RMI:IES %/ PALL>R c/ 1YAN>SIS (/ EACNDI1E e/ >EDEMA '/ S<IN DISEASES YES NO COMME NT

0/ SYSTEMIC EXAMINATION ITE M NORMA L ABNORM AL COMME NT

a/ EYES %/ EARS c/ N>SE

(/ >RAL 1A=I:Y/:6R>A: e/ NE1< '/ 6EAR:

./ LCNGS h/ A?D>MEN/6ER NIA >RIFI1ES i/ NER=>CS SYS:EM B/ MEN:AL S:A:E

k/ MCS1CL>S<ELE:AL SYS:EM

SECTION 0 1 IN2ESTIGATIONS
URINE TEST ITE M a/ AL?CMIN %/ SCGAR c/ MI1R>S1>PI1 (/ M>RP6INE e/ 1ANNA?IS '/ AMP6E:AMINE :YPE S:IMCLAN:S DATE TAKEN RESU LT

BLOOD TEST ITE M a/ 6EPA:I:IS ?s AN:IGEN %/ 6EPA:I:IS 1 c/ 6I= (/ =DRL / :P6A e/ MALARIAL PARASI:E DATE TAKEN RESU LT

CHEST X.RAY INFORMATION 16ES: FGRAY N>/ DA:E :A<EN PLA1E :A<EN REP>R:

SECTION 3. CERTIFICATION BY THE EXAMINATION DOCTOR

Please tick !" i# the appropriate %o&A I certi'* that I ha$e o# this (ate Mr/ /Ms hi)/herAG IN G>>D 6EAL:6 6A=ING :6E F>LL>DING MEDI1AL 1>NDI:I>N S" please State" Nric No/ e&a)i#e( A#( 'o,#(

CNDERG>ING :REA:MEN: F>RA Please State"

DateA

Si.#at,re o' DoctorA Na)e o' (octor @,ali'icatio# 6ospital/1li#ic Re.istratio# N,)%er A A A

>''icial sta)p

Re)ark %* Re.istrar >''iceA