GUIDELINES TO FILL IN HEALTH EXAMINATION REPORT
(for International Students)
1. Please read the instructions carefully before filling in the form.
2. Please fill in the form in the 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 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.
FORM G
UNIVERSITI UTARA MALAYSIA
HEALTH EXAMINATION REPORT
(FOR INTERNATIONAL STUDENT)
PLEASE USE CAPITAL LETTERS Passport size
SECTION 1 (To be completed by candidate) photo
(PART A)
FULL NAME (AS IN PASSPORT)
INTERNATIONAL PASSPORT NO.
NATIONALITY CONTACT NUMBER
DATE OF BIRTH AGE SEX MARITAL STATUS
MALE SINGLE
D D M M Y Y FEMALE MARRIED
ACADEMIC YEAR COURSE CODE SEMESTER
/
FACULTY MATRIC NO.
NEXT OF KIN
NEXT OF KIN’S ADDRESS
NEXT OF KIN’S CONTACT NUMBER .
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
IMMEDIATE
SELF
MEDICAL PROBLEMS FAMILY If “Yes” please state.
Yes No Yes No
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. Tuberculosis
13. Drug addiction
14. AIDS, HIV
15. History of surgery
16. Other illnesses
Current medication (Long term)
____________________________________ ___________________________________
____________________________________ ___________________________________
IMMUNIZATION HISTORY (where DATE IMMUNIZED
applicable)
1. Yellow Fever
2. BCG
3. Meningitis (Quadrivalent)
4. Hepatitis B
5. Others:
I hereby certify that the information given above is true. I understand that my application will be rejected if false
information is given.
Date Signature of Candidate
SECTION 2 - PHYSICAL EXAMINATION
To be filled by examining doctor
1. BASIC MEASUREMENT
HEIGHT : __________________ m BLOOD PRESSURE : ______________ mmHg
WEIGHT : __________________ kg PULSE RATE : ______________ / min
VISION TEST : Unaided : (R) _______ (L) ________ COLOUR VISION TEST :
Aided : (R) _______ (L) ________ NORMAL / ABNORMAL
2. GENERAL EXAMINATION
ITEM YES NO COMMENT
a. DEFORMITIES
b. PALLOR
c. CYANOSIS
d. JAUNDICE
e. OEDEMA
f. SKIN DISEASES
3. SYSTEMIC EXAMINATION
ITEM NORMAL ABNORMAL COMMENT
a. EYES (including funduscopy)
b. EARS
c. NOSE
d. ORAL CAVITY / THROAT
e. NECK
f. HEART
g. LUNGS
h. ABDOMEN / HERNIA ORIFICES
i. NERVOUS SYSTEM
j. MENTAL CONDITION
k. MUSCULOSKELETAL SYSTEM
SECTION 3 - INVESTIGATIONS
URINE TEST
ITEM DATE TAKEN RESULT
a. ALBUMIN
b. SUGAR
c. MICROSCOPIC
d. MORPHINE
e. CANNABIS
f. AMPHETAMINES TYPE
STIMULANT
BLOOD TEST
ITEM DATE TAKEN RESULT
a. HEPATITIS Bs ANTIGEN
b. HEPATITIS C
c. HIV
d. VDRL / TPHA
e. MALARIAL PARASITE
CHEST X-RAY INFORMATION
CHEST X-RAY NO.
DATE TAKEN
PLACE TAKEN
REPORT
SECTION 4 - CERTIFICATION BY THE EXAMINING DOCTOR
Please tick (√) in the appropriate box
I certify that I have on this date ___________________ examined
Mr / Ms ___________________________________ Passport No. ____________________ and found him / her:
IN GOOD HEALTH
HAS MEDICAL PROBLEM (Please State)
____________________________________________________
____________________________________________________
____________________________________________________
IS UNDERGOING TREATMENT FOR: (Please State)
____________________________________________________
____________________________________________________
____________________________________________________
Date Signature of Doctor :
Name of Doctor :
Qualification and :
Official stamp of Clinic
_________________________________________________________________________
Remarks by University Official:
