Académique Documents
Professionnel Documents
Culture Documents
No. Semakan: 01
Tarikh Kuatkuasa:01/08/2016
2.
3.
4.
5.
6.
7.
8.
PLEASE BRING ALONG CHEST X-RAY FILM AND REPORT FOR REGISTRATION.
9.
PLEASE ENSURE THE X-RAY FILM IS LABELLED WITH YOUR NAME AND DATE TAKEN
(IN ENGLISH).
11. THE UNIVERSITY HAS THE RIGHT TO REPEAT FULL MEDICAL CHECK-UP OR ANY
SPECIFIC LABORATORY TESTS IF THERE IS ANY DOUBT IN THE MEDICAL REPORT.
ALL COSTS INVOLVED SHALL BE BORNE BY THE CANDIDATES.
UKM-SPKP-PKes-PK01-BO06
No. Semakan: 01
Tarikh Kuatkuasa:01/08/2016
Passport size
photo
CONTACT NUMBER
DATE OF BIRTH
D
AGE
Y
ACADEMIC YEAR
SEX
MALE
FEMALE
COURSE CODE
FACULTY
MARITAL STATUS
SINGLE
MARRIED
SEMESTER
MATRIC. NO
NEXT OF KIN
NEXT OF KINS ADDRESS
[1]
UKM-SPKP-PKes-PK01-BO06
No. Semakan: 01
Tarikh Kuatkuasa:01/08/2016
Declaration of self and family illness. Explain in full if you or your family has any of the following illnesses.
3.
Mental illness
2.
4.
5.
6.
7.
8.
9.
SELF
Yes
No
IMMEDIATE
FAMILY
Yes
No
Allergy
Thyroid disease
12. Tuberculosis
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
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
[2]
UKM-SPKP-PKes-PK01-BO06
No. Semakan: 01
Tarikh Kuatkuasa:01/08/2016
HEIGHT : __________________ m
WEIGHT : __________________ kg
PULSE RATE
Aided
2. GENERAL EXAMINATION
ITEM
a. DEFORMITIES
NORMAL
YES
NO
: ______________ / min
ABNORMAL
COMMENT
b. PALLOR
c. CYANOSIS
d. JAUNDICE
e. OEDEMA
f. SKIN DISEASES
3. SYSTEMIC EXAMINATION
ITEM
NORMAL
ABNORMAL
b. EARS
c. NOSE
f. HEART
g. LUNGS
j. MENTAL CONDITION
k. MUSCULOSKELETAL SYSTEM
[3]
COMMENT
UKM-SPKP-PKes-PK01-BO06
SECTION 3 -
No. Semakan: 01
Tarikh Kuatkuasa:01/08/2016
INVESTIGATIONS
URINE TEST
ITEM
a. ALBUMIN
DATE TAKEN
RESULT
b. SUGAR
c.
MICROSCOPIC
d. MORPHINE
e. CANNABIS
f.
AMPHETAMINE TYPE
STIMULANTS
BLOOD TEST
ITEM
a. HEPATITIS Bs ANTIGEN
DATE TAKEN
b. HEPATITIS B ANTIBODY
c.
HEPATITIS C
d. HIV Ag/Ab
e. VDRL / TPHA
f.
MALARIAL PARASITE
PLACE TAKEN
REPORT
[4]
RESULT
UKM-SPKP-PKes-PK01-BO06
SECTION 4 -
No. Semakan: 01
Tarikh Kuatkuasa:01/08/2016
Signature of Doctor
Name of Doctor
Qualification
Hospital/Clinic
Dr.s Registration Number
Official stamp
_________________________________________________________________________
Remarks By University Official :
[5]