BorangPengakuandanPemeriksaanKesihatan

8/2/2019 BorangPengakuandanPemeriksaanKesihatan

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NameI.C. NoDate of BirthNamaNo. KPTarikh Lahir

Married [ Berkahwin]

Other : __________Lain-lain

Contact Number No. Untuk dihubungi

(H) R : (H/P) T/B:

SNILLNESS

YESNO1.

Psychiatric illness / (Sakit Jiwa)

2.Epilepsy / (Sawan)

SULITffd8ffe000104a464946000

101010060005f0000ffdb0043000d090a0b0a080d0b0a0b0e0e0d0f13201513121213271c1e17202e2931302e292d2c333a4a3e333646372c2d405741464c4e525352323e5a615a50604a51524fffdb0

043010e0e0e131113261515264f352d354f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4f4fffc0001108004500a703012200021101031101ffc4001f0000010501010101010100000000000000000102030405060708090a0bffc400b51000020103030204030505040

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

34e125f11718191a262728292a35363738393a434445464748

JABATAN PEMBANGUNAN SUMBER MANUSIAPEJABAT PENDAFTAR

HEALTH DECLARATION ANDMEDICAL EXAMINATION FORMBorang Pengakuan Dan Pemeriksaan Kesihatan

Instruction : (Kindly use BLACK ink ball pen to fil l up this form)(i) Health Declaration : in the completed by student(ii) Medical Examination : to completed by certified physicianNote : Student is responsible to retu rn this form to JPbSM once completed

Arahan : (Sila gunakan pen mata bulat berdakwat HITAM sahaja untuk mengisi borang ini)

(i) Pengakuan Kesihatan : diisi oleh pelajar(ii) Pemeriksaan Kesihatan : diisi oleh pegawai perubatan yang diiktirafNota: Pelajar adalah bertanggungjawab untuk mengembalikan borang yang telah lengkap diisi ke JPbSM

PERSONAL DETAILSMaklumat Peribadi

Sex: M [ ] F [ ] Marital Status : Single [ ]Jantina: L P Status Perkahwinan Bujang

Home AddressAlamat Kediaman

Name, relationship and address of next of kinNama hubungan dan alamat waris


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.Migraine / (Migrain)

4.Hysteria / (Histeria)

5.Allergis Rhinitis / (Resdung)

6.Asthma / (Lelah)

7.Tuberculosis / (Batuk Kering)

8.Hypertension (HPT) / (Darah Tinggi)

9.Diabetes Mellitus / (Kencing Manis)

10.Heart Diseases / (Penyakit Jantung)

11.

Thyroid Diseases / (Penyakit Tiroid)

12.Kidney Diseases / (Penyakit Buah Pinggang)

13.Gastric / (Penyakit Gastrik)

14.HIV/AIDS

15.Cancer / (Barah)

16.Veneral Diaseases / (Penyakit Kelamin)

17.Leukemia / (Leukimia)

Contact NumberNo. Untuk dihubungi

(H) R :

(H/P)T/B:

HEALTH DECLARATIONPengakuan Kesihatan

Have you ever suffered any of the following conditions?Pernahkah anda mengalami masalah-masalah kesihatan berikut?

Please mark x in appropnatecolumn Tandakan x diruang

berkenaan


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Hepatitis / (Hepatitis)

SNSYSTEMS

NORMALABNORMAL

Please State (Sila nyatakan)

Other illnesses / (Penyakit-penyakit lain)

Operation/Surgical / (Pembedahan)

Allergic/ (Alahan)

Family Medical History / (Sejarah Kesihatan Keluarga)

Disability/Handicap / (Kecacatan)

I hereby certify that the above information is true and complete, and agree that any

misrepresentation or deliberate omissions of a material fact on this form may result in my

not being permitted to enter a program, or may result in termination. I hereby grant

Human Resources Development Office of Registrar, permission to share information

contained in my Medical Examination Form.Saya dengan ini mengakui bahawa maklumat di atas adalah benar dan lengkap dan bersetuju sekiranya terdapat

maklumat yang tidak benar atau dengan sengaja tidak menyatakan perihal sebenar di dalam borang ini akanmenyebabkan saya tidak dibenarkan mengikuti program yang ditawarkan atau menghadapi kemungkinanditamatkan daripada program. Saya, dengan ini memberi kebenaran kepada Bahagian Biasiswa, JabatanPembangunan Sumber Manusia (JPbSM), Pejabat Pendaftar, UiTM untuk berkongsi maklumat yang terdapat didalam Borang Pemeriksaan Kesihatan saya.

Signature DateTandatangan Tarikh


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WEIGHTHEIGHTBLOOD PRESSUREPULSESKIN

COLOREYE VISION TEST (RT)EYE VISION (LT)

.Skin

2.Head

3.

Eyes

4.Ears

5.Nose

6.Mouth

7.Neck

8.Chest

9.Breast

10.Cardiovascular

11.Syncope

12.Chest Pain

CONFIDENTIAL MEDICAL EXAMINATION

(Physician must complete all questions and give additional comment where necessary. Kindlynote that physician is responsible for the information, suggestions and recommendation

regarding the students health given in this form)

Student Name Date of Birth/ /

PHYSICAL EXAMINATION

Are there abnormalities of the following systems? If yes, describe fullyusing additional sheet if necessary


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Heart Murmur

14.Abdomen

15.Genitourinary

16.Extremities

17.Neurologic

NAD

WBC

RBC

PROTEIN

GLUCOSE

POSITIVE

NEGATIVE

POSITIVE

NEGATIVE

Medicallyfit

Unfit

Limited Capability

URINE TEST

HEPATITIS TEST

PREGNANCY TEST

Is the student now under treatment for any physical or emotional condition?

Do you have any recommendations for the health care of this student?

By history and physical examination, is this student a carrier of any communicable disease?

RESULT

Physician Signature Date

Post and Qualification Note : In completing this form, particularattention should be paid to the following points :

(a) X-ray of chest to rule out any tuberculosis or chronic pulmonary disease : where

the film is entirely normal it needs not be forwarded bur if any abnormality is noted thefilm should be sent with this report.

(b) Kidneys no evidence of renal lesion should be present

(c) Eyesight severe errors of refraction should be not be passed as theseshould only give trouble during the years of study.

(d) Hearing deafness should be considered a definite bar

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