附件六：博特拉大学体检表.pdf

Borang RME / IPT International HEALTH EXAMINATION GUIDELINES 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. PROSPECTIVE CANDIDATES ARE STRONGLY ADVISED TO UNDERGO VACCINATION FOR HEPATITIS B BEFORE JOINING UNIVERSITY PUTRA MALAYSIA. 7. PLEASE ATTACH ALL THE ORIGINAL LABORATORY RESULTS AND THE RESULTS MUST BE REPORTED IN ENGLISH. 8. THE UNVERSITY / COLLEGE ONLY ACCEPTS MEDICAL EXAMINATION DONE WITHIN 60 DAYS BEFORE REGISTRATION OR WITHIN 30 DAYS AFTER REGISTRATION. 9. PLEASE BRING ALONG THE CH EST 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 6 MONTHS PRIOR TO REGISTRATION 10. 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 CAND IDATES. 11. 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 APPLICANT HAS GIVEN FALSE INFORMATION IN THE HEALTH EXAMINATION REPORT OR ANY SUPPORTING DOCUMENTS. 12. IT IS STRONGLY RECOMMENDED THAT THIS HEALTH EXAMINATION BE PERFORMED IN MALAYSIA BY MALAYSIAN MEDICAL PRACTITIONERS TO ENSURE COMPLIANCE WITH THE MALAYSIAN MINISTRY OF HEALTH GUIDELINES. 0 Borang RME / IPT International HEALTH CONDITIONS FOR ENTRY OF INTERNATIONAL STUDENTS INTO UPM (As Per Health Examination Guidelines For Entry Into Malaysian Higher Educational Institutions Issued By The Malaysian Ministry Of Higher Education) A. TRANSMITTABLE ILLNESSES NO TYPES OF ILLNESSES/COMPLICATIONS ACTION TAKEN BASED ON TIME OF DETECTION EXAMPLES COMMENCEMENT OF COURSE OF STUDY  Student registration will not be accepted DURING COURSE OF STUDY 1  Transmittable  Difficult to cure on a long-term basis  High treatment cost  HIV / AIDS  Hepatitis B  Hepatitis C 2  Transmittable  Treatable with a specific course of treatment  Tuberculosis  Defer registration until completion of treatment (up to 2 semester)  Need confirmation by the attending doctor  Allowed to continue with course of study  Allowed to defer course of study (if necessary) up to 2 semesters only 3  Transmittable  Treatable with a short course of treatment  Malaria  Typhoid  Syphilis (VDRL)  Can be accepted to register  Required to undergo treatment  Financed by health scheme  Allowed to continue with course of study  Allowed to go on medical leave (if necessary) up to 2 weeks only  Treatment is financed by health scheme 4  Transmittable diseases declared as an epidemic by the Malaysian Health Ministry  Japanese encephalitis  SARS  Avian flu  Student registration will will not be accepted  In compliance with the latest health circulars issues by the Malaysian Ministry of Health and WHO B. CHRONIC NON-TRANSMITTABLE ILLNESSES NO TYPES OF ILLNESSES/COMPLICATIONS Allowed to proceed with studies but with the following terms and conditions:  Student will finance their own treatment cost  Permission is granted to pursue the current course only  Allowed to defer studies up to 2 semesters only (if necessary) ACTION TAKEN BASED ON TIME OF DETECTION EXAMPLES COMMENCEMENT OF COURSE OF STUDY A report is required from the specialist attending. Student can be accepted for registration if:  There are no symptoms for more than 12 months; and  No longer undergoing treatment  Undergoing treatment but student has agreed to selffinance the treatment costs. DURING COURSE OF STUDY 1  Illnesses which can pose a risk to self or others  Recurring symptoms which effect studies  Epilepsy  Schizop  hrenia  Depression 2  Symptoms expected to persist for extended periods of time  Obvious and serious symptoms  Lengthy period of treatment  Dialysis  Cancer  Student registration will be rejected Students will be allowed to continue with studies on condition that:  Symptoms do not affect course of study  Students will self-finance the treatment costs 3  Addictions  Drugs  Complete course of study 4  Require ongoing medication regime  No serious symptoms  Treatment does not effect studies  Hypertension  Diabetis Mellitus  Asthma  Dyslipidemia  Student registration will be rejected Student will be accepted on condition:  Treatment does not interfere with course of study  Student has agreed to selffinance the treatment costs. 1 Continue with course of study if:  Symptoms do not effect course of study.  Student agrees to self-finance the treatment costs.  Allowed to continue with currentcourse of study only Students will be allowed to continue with studies on condition that  Treatment does not interfere with course of study  Student has agreed to selffinance the treatment costs. Borang RME / IPT International UNIVERSITI PUTRA MALAYSIA HEALTH EXAMINATION REPORT PLEASE USE CAPITAL LETTERS Passport size photo 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 MARITAL STATUS MALE SINGLE FEMALE MARRIED COURSE CODE SEMESTER / PROGRAMME MATRIC NO. NEXT OF KIN NEXT OF KIN’S ADDRESS NEXT OF KIN’S CONTACT NUMBER . RELATIONSHIP . 2 Borang RME / IPT International 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 FAMILY SELF MEDICAL PROBLEMS Yes 1. No Yes If “Yes” please state. No AIDS, HIV 2. Hepatitis B/C Carrier 3. Tuberculosis 4. Drug addiction 5. Congenital or inherited disorder 6. Allergy 7. Mental illness 8. Fits, stroke, other neurological disease 9. Diabetes Mellitus 10. Hypertension 11. Heart or vascular disease 12. Asthma 13. Thyroid disease 14. Kidney disease 15. Cancer 16. History of surgery 17. Other illnesses Current medication (Long term) ____________________________________ ____________________________________ ____________________________________ ____________________________________ IMMUNIZATION HISTORY DATE IMMUNIZED 1. Yellow fever 2. BCG 3. Typhoid 4. Meningitis (Quadrivalent) 5. Hepatitis B 6. Others I hereby certify that the information given above is true. I understand that my application will be rejected if there is any false information given. Date Signature of candidate 3 Borang RME / IPT International SECTION 2 - PHYSICAL EXAMINATION To be filled by examining doctor 1. BASIC MEASUREMENT HEIGHT : __________________ m BLOOD PRESSURE : ______________ mmHg WEIGHT : __________________ kg PULSE RATE VISION TEST : Unaided : (R) _______ (L) ________ COLOUR BLIND TEST : Aided : (R) _______ (L) ________ NORMAL : ______________ / min / 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 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 4 COMMENT Borang RME / IPT International SECTION 3 - INVESTIGATIONS URINE TEST ITEM DATE TAKEN RESULT DATE TAKEN RESULT a. ALBUMIN b. SUGAR c. MICROSCOPIC d. MORPHINE e. CANNABIS f. AMPHETAMINES g. METHAMPHETAMINES BLOOD TEST ITEM a. HEPATITIS B ANTIGEN b. HEPATITIS B ANTIBODY c. HEPATITIS C d. HIV e. VDRL / TPHA f. MALARIAL PARASITE CHEST X-RAY INFORMATION CHEST X-RAY NO. DATE TAKEN PLACE TAKEN REPORT 5 Borang RME / IPT International 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 : 6 Borang RME / IPT International FOR VISA APPLICATION 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 : 7