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Health Examination Guidelines For Entry Into Universiti Tunku Abdul Rahman

1. 2.

Please read the instructions carefully before filling in the form. This form has 4 sections: (a) (b) Section 1 (Parts A and B) to be filled by the candidate; and Sections 2, 3 and 4 to be filled by the examining doctor. Please complete all the tests required in this form.

3. 4. 5. 6. 7. 8.

The university only accepts medical examination done within 60 days before registration or within 30 days after registration. Please attach all original laboratory result. Please bring along chest x-ray film and report during registration. Please ensure the x-ray film is labelled with your name and date taken. Chest x-ray done within 6 months prior to registration can be accepted. The university reserves the right to repeat full medical check-up or any specific laboratory tests should there be any doubt in the medical report submitted. All costs involved shall be borne by the candidates.

Universiti Tunku Abdul Rahman Form Title: HEALTH EXAMINATION REPORT Form Number: FMRev No. : 0 Effective Date: Page No: 1 of 5 DACE-014 01/01/2011

PLEASE USE CAPITAL LETTERS SECTION 1 (To be completed by candidate) (PART A)

Passport size photo

FULL NAME: _______________________________ CONTACT NUMBER: ________________________ MARITAL STATUS: SINGLE* / MARRIED*

REGISTRATION NO.: ________________ DATE OF BIRTH: ___________________ GENDER: MALE* / FEMALE*

PROGRAMME OF STUDY: __________________________________________________________ NEXT OF KIN : ____________________________________________________________

________ NEXT OF KIN’S CONTACT NUMBER: _________________________________________________ NEXT OF KIN’S ADDRESS: _________________________________________________________ ____________________________________________________________

____________________ * Delete whichever not applicable

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Universiti Tunku Abdul Rahman Form Title: HEALTH EXAMINATION REPORT Form Number: FMRev...