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Health Declaration

This document contains a health declaration and medical examination form for students applying for a scholarship from the Ministry of Higher Education Malaysia. The form collects personal details and medical history from the student, and is also completed by a certified physician conducting a physical exam. The physician must examine all body systems, perform various tests, and indicate whether the student is medically fit or unfit to participate in studies based on the results. Special attention is paid to ruling out conditions like tuberculosis, kidney or eye issues, or hearing loss that could interfere with studying.

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464 views5 pages

Health Declaration

This document contains a health declaration and medical examination form for students applying for a scholarship from the Ministry of Higher Education Malaysia. The form collects personal details and medical history from the student, and is also completed by a certified physician conducting a physical exam. The physician must examine all body systems, perform various tests, and indicate whether the student is medically fit or unfit to participate in studies based on the results. Special attention is paid to ruling out conditions like tuberculosis, kidney or eye issues, or hearing loss that could interfere with studying.

Uploaded by

ust dol
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 5

CONFIDENTIAL PROGRAMME : SLAB

SCHOLARSHIP DIVISION
Bahagian Biasiswa

MINISTRY OF HIGHER EDUCATION MALAYSIA


Kementerian Pengajian Tinggi Malaysia (KPTM)

HEALTH DECLARATION AND MEDICAL EXAMINATION FORM


Borang Pengakuan dan Pemeriksaan Kesihatan

Instruction : ( Kindly use BLACK ink ball pen only to fill up this form )

(i) Health Declaration - to be completed by student


(ii) Medical Examination - to be completed by certified physician
Note : Student is responsible to returnn this form to MOHE once completed

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

(i) Pengakuan Kesihatan - diisi oleh pelajar


(ii) Pemeriksaan Kesihatan - diisi oleh pegawai perubatan yang diiktiraf
Nota : Pelajar adalah bertanggungjawab untuk mengembalikan borang yang telah lengkap
diisi ke KPTM

PERSONAL DETAILS
Maklumat Peribadi

Name : I.C.No : Date of Birth :


Nama : No.K/P : Tarikh Lahir :

/ /

Sex : M [ ] F[ ] Marital Status : Single [ ] Married [ ] Other : _________


Jantina: L P Status Perkahwinan: Bujang Kahwin Lain-lain

Home Address Contact Number


Alamat Kediaman No untuk dihubungi

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

Name, relationship and address of next of kin Contact Number


Nama, hubungan dan alamat waris No untuk dihubungi

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

1
HEALTH DECLARATION
Pengakuan Kesihatan

Have you ever suffered any of the following conditions ?


Pernahkan anda mengalami masalah-masalah kesihatan berikut ?

Please mark x in appropriate column


Tandakan x di ruang berkenaan

SN ILLNESS YES NO
1. Psychiatric illness / ( Sakit Jiwa )
2. Epilepsy / ( Sawan )
3. Migraine / ( Migrain)
4. Hysteria / ( Histeria)
5. Allergic Rhinitis / ( Resedung )
6. Asthma / ( Lelah )
7. Tuberculosis ( PTB ) / ( Batuk Kering )
8. Hypertension ( HPT ) / ( Darah Tinggi )
9. Diabetes Mellitus ( DM ) / ( 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. Venereal Diseases / ( Penyakit Kelamin )
17. Leukemia / ( Leukimia )
18. Hepatitis / ( Hepatitis )

Please State ( Sila Nyatakan )

Other illnesses / ( Penyakit-penyakit lain )

Operation / Surgical / ( Pembedahan )

Allergic / ( Alahan )

2
Family Medical History ( Sejarah Perubatan 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
Sclolarship Division, Ministry of Higher Education, permission to share information
contained in my Medical Examination Form.

Saya dengan ini mengaku 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 akan
menyebabkan saya tidak dibenarkan mengikuti program yang ditawarkan atau menghadapi kemungkinan
ditamatkan daripada program. Saya, dengan ini memberi kebenaran kepada Bahagian Biasiswa, KPT untuk
berkongsi maklumat yang terdapat di dalam Borang Pemeriksaan Kesihatan saya.

Signature Date
Tandatangan Tarikh

3
CONFIDENTIAL

MEDICAL EXAMINATION
( Physician must complete all question and give additional comment where necessary. Kindly
note that physician is responsible for the information, suggestion and recommendation
regarding the student’s health given in this form )

Student Name Date of Birth


/ /

PHYSICAL EXAMINATION

WEIGHT HEIGHT

BLOOD PRESSURE PULSE

SKIN COLOR

EYE VISION TEST (RT) EYE VISION (LT)

Are there abnormalities of the following systems? If yes, describe fully


using additional sheet if necessary.

SN SYSTEMS NORMAL ABNORMAL COMMENT


1 Skin
2 Head
3 Eyes
4 Ears
5 Nose
6 Mouth
7 Neck
8 Chest
9 Breasts
10 Cardiovascular
11 Syncope
12 Chest Pain
13 Heart Murmur
14 Abdomen
15 Genitourinary
16 Extremities
17 Neurologic
4
URINE TEST
NAD WBC RBC PROTEIN GLUCOSE

HEPATITIS TEST

POSITIVE NEGATIVE

PREGNANCY TEST
POSITIVE NEGATIVE

If 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 ang physical examination, is this student a carrier of any communicable disease ?

RESULT
Medically fit Unfit Limited Capability

Physician Signature Date

Post and Qualification

Note : In completing this form, particular attention 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, but if any abnormality is noted the film
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 these should only
give trouble during the years of study

d) Hearing – deafness should be considered a definite bar


5

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