Format

Attachment 3:

GUIDELINES TO FILL IN HEALTH EXAMINATION REPORT

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 2 SECTIONS
-

SECTION 1 (PART A AND B) TO BE FILLED BY THE CANDIDATES

-

SECTION 2 TO BE FILLED BY THE EXAMINING DOCTOR

5. PLEASE COMPLETE ALL THE TESTS REQUIRED IN THIS FORM.
6. PLEASE ATTACH ALL THE ORIGINAL LABORATORY RESULTS.
7. PLEASE BRING ALONG THE CHEST X-RAY FILM AND REPORT.
a

PLEASE ENSURE THE X-RAY FILM IS LABELLED WITH YOUR NAME AND DATE
TAKEN (IN ENGLISH)

b

CHEST X-RAY MUST BE DONE WITHIN 3 MONTHS PRIOR TO REGISTRATION

8. UNIVERSITY ONLY ACCEPTS MEDICAL EXAMINATION DONE WITHIN 3 MONTH
BEFORE REGISTRATION.
9. UNIVERSITY CONCERNED HAS THE RIGHT TO REPEAT THE MEDICAL CHECK-UP
SHOULD THERE BE ANY DOUBT OF THE MEDICAL REPORT. ALL COSTS INVOLVED
WILL BE PAID BY THE CANDIDATES.

Borang RME / IPT Malaysia

UNIVERSITI UTARA MALAYSIA
HEALTH EXAMINATION REPORT

Passport size
photo

PLEASE USE CAPITAL LETTERS

SECTION 1 (To be completed by candidate)
(PART A)

FULL NAME (AS IN PASSPORT)

INTERNATIONAL PASSPORT NO.

NATIONALITY

CONTACT NUMBER

DATE OF BIRTH
D

D

M

M

AGE

Y

Y

ACADEMIC YEAR

SEX
MALE
FEMALE

M ARITAL STATUS
SINGLE
MARRIED

COURSE CODE

SEMESTER

/
FACULTY

M ATRIC NO.

NEXT OF KIN

NEXT OF KIN’S ADDRESS

NEXT OF KIN’S CONTACT NUMBER

.

1

Borang RME / IPT Malaysia

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

Yes
1.

Fits, stroke, other neurological disease

5.

Diabetes Mellitus

6.

Hypertension

7.

Heart or vascular disease

8.

Asthma

9.

If “Yes” please state....