IIUM HEALTH AND WELLNESS CENTRE INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA HEALTH EXAMINATION REPORT (for International Students)

INSTRUCTION: PLEASE FILL IN USING CAPITAL LETTERS SECTION 1 (To be completed by candidates) (PART A)

PASSPORT SIZE PHOTO

FULL NAME (AS IN PASSPORT)

INTERNATIONAL PASSPORT NO.

NATIONALITY

CONTACT NUMBER

DATE OF BIRTH D D M M Y ACADEMIC YEAR / PROGRAMME OF STUDY Y

AGE

SEX MALE FEMALE STUDENT ID

MARITAL STATUS SINGLE MARRIED

PROGRAMME CODE

NEXT OF KIN

NEXT OF KINS ADDRESS

NEXT OF KINS 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 MEDICAL PROBLEMS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Congenital or inherited disorder Allergy Mental illness Fits, stroke, other neurological disease Diabetes Mellitus Hypertension Heart or vascular disease Asthma Thyroid disease Kidney disease Cancer Tuberculosis Drug addiction AIDS, HIV History of surgery Other illnesses

SELF Yes No

IMMEDIATE FAMILY Yes No

If Yes please state.

Current medication (Long term) ___________________________________ _________________________________ ___ ___________________________________ _____________________________________ IMMUNIZATION HISTORY (where applicable) 1 2 3 4 5
Yellow Fever BCG Meningitis (Quadrivalent) Hepatitis B Others:

DATE IMMUNIZED

I hereby certify that the information given above is true. I understand that my application/ registration will be rejected/cancelled if there is any false information given.

.. Date

. Signature of candidate
2

SECTION 2 - PHYSICAL EXAMINATION To be filled by examining doctor 1. BASIC MEASUREMENT HEIGHT : __________________ m BLOOD PRESSURE : ______________ mmHg VISION TEST : Unaided : (R) _______ (L) ________ Aided : (R) _______ (L) ________ 2. GENERAL EXAMINATION ITEM a. DEFORMITIES b. PALLOR c. CYANOSIS d. JAUNDICE e. OEDEMA f. SKIN DISEASES WEIGHT : __________________ kg PULSE RATE : ______________ / min COLOUR VISION TEST : NORMAL / ABNORMAL

YES

NO

COMMENT

3. SYSTEMIC EXAMINATION ITEM a. b. c. d. e. f. g. h. i. j. k. EYES (including funduscopy) EARS NOSE ORAL CAVITY / THROAT NECK HEART LUNGS ABDOMEN / HERNIA ORIFICES NERVOUS SYSTEM MENTAL CONDITION MUSCULOSKELETAL SYSTEM

NORMAL ABNORMAL

COMMENT

SECTION 3 - INVESTIGATIONS URINE TEST ITEM a. ALBUMIN DATE TAKEN RESULT

b. SUGAR c. MICROSCOPIC

d. MORPHINE e. f. CANNABIS AMPHETAMINES TYPE STIMULANT

BLOOD TEST ITEM a. HEPATITIS Bs ANTIGEN DATE TAKEN RESULT

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 HAVING THE FOLLOWING MEDICAL COMPLICATION (S) (Please State) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ UNDERGOING TREATMENT FOR: (Please State) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

Signature of Doctor Name of Doctor Qualification Hospital/Clinic : : :

Date

______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

Registration Number : Official stamp :

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