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. PLEASE ATTACH ALL THE ORIGINAL LABORATORY RESULTS.
7. PLEASE BRING ALONG THE CHEST 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 3 MONTHS PRIOR TO REGISTRATION
8. UNIVERSITY ONLY ACCEPTS MEDICAL EXAMINATION DONE WITHIN 3 MONTH
BEFORE REGISTRATION.
9. UNIVERSITY CONCERNED HAS THE RIGHT TO REPEAT THE MEDICAL CHECK-UP
SHOULD THERE BE ANY DOUBT OF THE MEDICAL REPORT. ALL COSTS INVOLVED
WILL BE PAID BY THE CANDIDATES.
Borang RME / IPT Malaysia
UNIVERSITI UTARA MALAYSIA
HEALTH EXAMINATION REPORT
Passport size
photo
PLEASE USE CAPITAL LETTERS
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
MALE
FEMALE
M ARITAL STATUS
SINGLE
MARRIED
COURSE CODE
SEMESTER
/
FACULTY
M ATRIC NO.
NEXT OF KIN
NEXT OF KIN’S ADDRESS
NEXT OF KIN’S CONTACT NUMBER
.
1
Borang RME / IPT Malaysia
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
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