Buku Panduan Kemasukan Pelajar Baharu Sesi 2012/2013
UMK 1a
SENARAI SEMAKAN UNIT KESIHATAN MAHASISWA UNIVERSITI MALAYSIA KELANTAN *
NO. PENDAFTARAN
*
NO. KAD PENGENALAN
*
NAMA
:
-
-
……………………………………………………………………………
PERKARA 1.
Laporan Kesihatan (Jika ada)
2.
Gambar Ukuran Pasport (1 keping)
3.
Borang Perakuan Bius/Pembedahan
4.
Filem X-Ray Saiz Penuh
ADA
Hendaklah dipenuhi oleh calon untuk semakan pada hari pendaftaran.
20
TIADA
Buku Panduan Kemasukan Pelajar Baharu Sesi 2012/2013
UMK 1b
Gambar ukuran pasport
UNIVERSITI MALAYSIA KELANTAN LAPORAN PEMERIKSAAN KESIHATAN HEALTH EXAMINATION REPORT
Passport size photo Untuk diisi oleh calon To be completed by candidate
Sila isikan dengan huruf besar Please use block letters
BAHAGIAN 1 PART 1 TAHUN AKADEMIK/ ACADEMIC YEAR
KOD PROGRAM/ PROGRAMME CODE
SEMESTER
/ FAKULTI/ FACULTY
NO.MATRIK/ MATRIC NO.
NAMA PENUH/ FULL NAME
NO. KAD PENGENALAN/ PASPORT/ IDENTITY CARD/ PASSPORT NO.
WARGANEGARA/ NATIONALITY
UMUR/AGE
TARIKH LAHIR/ DATE OF BIRTH D D
LELAKI/ MALE
PEREMPUAN/ FEMALE
BUJANG/ SINGLE
M M
Y
Y
Y
Y
KAHWIN/ MARRIED
NAMA PENJAGA/ NAME OF GUARDIAN
ALAMAT SURAT MENYURAT PENJAGA/ GUARDIAN MAILING ADDRESS
NO. TELEFON RUMAH/ HOUSE TELEPHONE NO.
NO. TELEFON PEJABAT/ OFFICE TELEPHONE NO.
21
Buku Panduan Kemasukan Pelajar Baharu Sesi 2012/2013
BAHAGIAN 2 – Sila tandakan ( / ) di kotak berkenaan. PART 2 – Please tick ( / ) in the relevant box. Pengakuan penyakit diri dan keluarga. Jelaskan jika anda menghidap penyakit berikut atau penyakit yang lain yang serius. Declaration of self and family illness. Explain in full if you or your family has any of the following or other serious illnesses. Masalah / Problems
Sendiri / Self Ya / Yes
Tidak / No
Keluarga / Family Ya / Yes
Jika “Ya” sila nyatakan / If “Yes” please state.
Tidak / No
Penyakit sejak lahir atau baka/ Congenital or inherited disorder Alahan / Allergy Sakit jiwa / Mental illness Sawan, angin ahmar, penyakit saraf / Fits, stroke, other neurogical Kencing manis/ Diabetes Darah tinggi/ Hypertension Jantung atau salur darah/ heart or vascular disease Asma/ Asthma Sakit buah pinggang/ Kidney disease Barah/ Cancer Batuk kering/ Tuber culosis Ketagihan dadah/ Drug addiction AIDS, HIV Sejarah pembedahan/ History of surgery Penyakit serius lain/ Other serious illnesses
Sejarah imunisasi / Immunization history a) b) c) d) e)
Tarikh imunisasi / Date immunized
Yellow fever BCG Typhoid Meningtis (Quadrivalent) Hepatitis B
Saya dengan ini mengaku bahawa keterangan yang diberi di atas adalah benar. / I hereby certify that the information given above is true.
…………………………… Tarikh / Date
………………………… Tandatangan calon / Signature of candidate
22
Buku Panduan Kemasukan Pelajar Baharu Sesi 2012/2013
PART 3
TO BE COMPLETED BY EXAMINING DOCTOR 1.
General examinations a. Height c. Pulse
cm cm Per minute Yes
b. Weight d. BP
No
Yes No
a. Pallor c. Oedema e. Lymphnodes
2.
b. Cyanosis d. Jaundice f. Skin
Eyes a. b. c. d.
Unaided visio n Aided vision Colour vision Funduscopy
Buku Panduan Kemasukan Pelajar Baharu Sesi 2012/2013
PART 4 * 11.
Urine a. Sugar
12.
13.
b. Albumin
c. Microscopy ________________
Urine Drugs: a. Opiate
b. Cannabis
________________
c. Amphetamines
d. Methamphetamines
________________
a. Malarial parasite
b. VDRL
________________
c. Hepatitis B Ag
d. Hepatitis B Ad
________________
e. Hepatitis c
f. HIV
________________
Blood
* Note: Malaysian students are required to do 11a, 11b and 11c only. PART 5 Certification by doctor: Please tick ( ) in the appropriate box. I hereby certify that I have on this date ______________________________ examined _______________________________ Identification card number / Passport number _______________________ and found: The above named is in good health The above named has ________________________________________ The above named is undergoing treatment for ________________________________________
Date __________________
Signature of Doctor
: ____________________
Name of Doctor
: ____________________
Qualification and Official stamp of Clinic
: ____________________
Remarks By UMK Medical Officer :
24
Buku Panduan Kemasukan Pelajar Baharu Sesi 2012/2013
UMK 1c
PERAKUAN KEBENARAN BIUS (ANAESTHETIC) DAN PEMBEDAHAN AUTHORISATION FOR ANAESTHESIA AND SURGICAL PROCEDURE Pengarah / Pegawai Perubatan Universiti Malaysia Kelantan Pengkalan Chepa Kelantan Saya
: _____________________________________________________ ; ______________________________________ (bapa / ibu / penjaga) (nombor kad pengenalan/nombor passport)
dengan ini memberi kuasa kepada tuan menandatangani bagi pihak saya sekiranya ______________________________________________________________ ; _______________________________________ ( pelajar) (nombor kad pengenalan/nombor passport) perlu menjalani prosedur bius atau pembedahan semasa kecemasan sedangkan saya tidak dapat hadir pada masa yang diperlukan. Saya tidak akan mengambil sebarang tindakan terhadap UNIVERSITI MALAYSIA KELANTAN dari sebarang tuntutan jika berlaku sebarang kemungkinan yang timbul daripada prosedur tersebut. I _____________________________________________________________; _____________________________________ (father / mother / guardian) (identity card number / passport number) hereby authorize you to sign on my behalf for emergency anaesthesia or surgical procedure on ______________________________________________________________; _____________________________________ (student) (identity card number / passport number) in my absence when required. I will absolve the University Malaysia Kelantan of any claims from any unfavourable consequences which may arise from the said procedure. Nama bapa/ibu/penjaga Name of father/mother/guardian
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