application form, health form with rules and regulation

7/30/2019 Application Form, Health Form With Rules and Regulation

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((,Education MALAYSIA

REQUIREMEI\JTS FOR PHOTOGRAPHS

o in colour and identical, not black and white= taken against a BLUE background 50 millimetres (mm) high x 35 mm wide

Education Malaysia Global Services

o be free from reflection or glare on spectacles, the frames of which must not cover the eyese free from shadowso taken with the eyes open and clearly visible (with no sunglasses or tinted spectacles, and\no

hair across the eyes)- if possible, recommend photographs without spectacles to avoid therisk of rejection because of glare or reflection

with the subject facing forward, looking straight at the camera with a neutral expression with the mouth closed (no grinning, frowning or raised eyebrows)


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HEALTH EXAMINATION GUIDELINESFOR ENTRY INTO

MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS

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 4 SECTIONS ;

(a ) SECTION 1 (PART A AND B) TO BE FILLED BY THE APPLICANT ; AND( b ) SECTION 2, 3 AND 4 TO BE FILLED BY THE EXAMINING DOCTOR

5. PLEASE COMPLETE ALL THE TESTS REQUIRED IN THIS FORM.6. THE UNIVERSITY I COLLEGE ONLY ACCEPTS MEDICAL EXAMINATION DONE WITHIN

Lampiran A


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PLEASE USE CAPITAL LETTERS

HEALTH EXAMINATION REPORTFOR INTERNATIONAL STUDENTAND ACCOMPANYING PERSON

SECTION 1 (To be completed by candidate)(PART A)FULL NAME (AS IN PASSPORT)

Passport sizephoto

I I I I I Fll---t--1 1---{-1 --t-1 --1:----+--+1-r-1 ---+--1--+--+11-l--1 --t--t-1 --t-1 1--+-1-t--1:-1--+---ilINTERNATIONAL PASSPORT NO.I I I I INATIONALITYI I I I I CONTACT NUMBERI I I I I I I I I I I


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SECTION 1(PART B)- Please tick (.,;) in the relevant boxDedaration 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 I sisters

SELF IMMEDIATEMEDICAL PROBLEMS FAMILY If "Yes" please stateYES NO YES NO

1. Congenital or inherited disorder2. Allergy3. Mental illness4. Fits, stroke, other neurological disease .5. Diabetes Mellitus6. Hypertension7. Heart or vascular disease8. Asthma9. Thyroid disease10. Kidney disease11. Cancer12. Tuberculosis13. Drug addiction14. AIDS, HIV15. History of surgery16. Other illnesses

Current medication (Long Term)


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SECTION 2 - PHYSICAL EXAMINATIONTo be filled by examining doctor

1. BASIC MEASUREMENTHEIGHT : mWEIGHT : kg

VISION TEST : Unaided : (R) _ _ (L)Aided : (R) (L)

2. GENERAL EXAMINATIONITEM I YESa. DEFORMITIES

b. PALLORc. CYANOSISd. JAUNDICEe. OEDEMAf. SKIN DISEASES

2. GENERAL EXAMINATIONITEM INORMAL

BLOOD PRESSURE : mmHgPULSE RATE: /min

COLOUR VISION TEST :NORMAL I ABNORMAL

NO I COMMENT --_.:::_I

ABNORMAL COMMENT


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SECTION 3 - INVESTIGATIONS

URINE TESTITEM DATE TAKEN COMMENT

a. ALBUMINb. SUGARc. MICROSCOPIC Id. MORPHINEe. CANNABISf. AMPHETAMINES TYPE

STIMULANT

BLOODTEST- TrEM-----------r--DATE-TAKEN ___r _______COMMENT-a. HEPATITIS Bs ANTIGENb. HEPATITIS Cc. HIVd. VDRLITPHA Ie. MALARIAL PARASITE


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SECTION 4 - CERTIFICATION BY THE DOCTORPlease tick (.../) in the appropriate boxI certify that I have on this date________ examinedMr I Ms Passport No._____and found him I her :-

D IN GOOD HEALTHD HAVING THE FOLLOWING MEDICAL COMPLICATIONS (S) (Please State)

D UNDERGOING TREATMENT FOR: (Please State)


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"

Certified: Duplicates of original documents, certified as exact reproductions, usually by the officer responsible for issuing or keeping theoriginal, or by a solicitor, notary public, justice ofthe peace or any ot her person authorised to t ake a statutor y declaration. A certifiedcopy should carry a certificate, stamp or seal, and the certifier's signature.

If you send us a document that is not in English or Bahasa Malaysia in suppo rt of your application, this document must be accompanied by afull translation into English that can be independently verified by EMGS.

The original translation must contain:.

a) confirmation from the translator or translation company that it is an accurate translation ofthe original document;b) the date ofthe translation;c) the full name and signature ofthe t ranslator or of an authorised official of th e translation compal'ly; and th e translator or translation

company's contact detai ls.

Student Pass Document R e q u i n ~ m e n t s (IHE) v1 .6

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