IMC Health Examination Form

HEALTH EXAMINATION GUIDELINES
FOR ENTRY INTO

MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS
INTERNATIONAL MEDICAL COLLEGE
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) SECTION1 (PART A AND B) TO BE FILLED BY THE CANDIDATE; 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 / COLLEGE ONLY ACCEPT MEDICAL EXAMINATION DONE WITHIN 60

DAYS BEFORE REGISTRATION OR WITHIN 30 DAYS AFTER REGISTRATION.
7. PLEASE ATTACH ALL THE ORIGINAL LABORATORY RESULTS.
8. PLEASE BRING ALONG CHEST X-RAY REPORT FOR REGISTRATION.

FLIM /CD WILL BE REQUESTED BY THE COLLEGE AS AND WHEN NECCEASARY.
9. PLEASE ENSURE THE X-RAY FILM/CD IS LABELED WITH YOUR NAME AND DATE TAKEN.
(IN ENGLISH).
10. CHEST X-RAY DONE WITHIN 6 MONTHS PRIOR TO REGISTRATION CAN BE ACCEPTED.
11. THE COLLEGE RESERVES THE RIGHT TO REPEAT FULL MEDICAL CHECK-UP OR ANY SPECIFIC
LABORATORY TESTS SHOULD THERE BE ANY DOUBT IN THE MEDICAL REPORTS
SUBMITTED. ALL COSTS INVOLVED SHALL BE BORNE BY THE CANDIDATE.
12. THE COLLEGE RESERVES THE RIGHT TO REJECT ANY APPLICATION :-

(A) BASED ON THE RESULTS OF THE HEALTH EXAMINATION; OR
(B) SHOULD THERE BE ANY EVIDENCE THAT THE APPLICANT HAS GIVEN FALSE
INFORMATION IN THE HEALTH EXAMINATION REPORT OR ANY SUPPORTING
DOCUMENTS.
13. THE COLLEGE RESERVES THE RIGHT TO TERMINATE/EXPEL THE CANDIDATE/STUDENT

IF THE MEDICAL CHECK-UP DOES NOT PASS THE NURSING BOARD GUIDELINES.
PAGE 1 OF 7
Revised 10/2017
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HEALTH EXAMINATION REPORT

FOR IMC STUDENT
PLEASE USE CAPITAL LETTERS
SECTION 1 (to be completed by candidate)

(PART A)
FULL NAME (as state in MYKAD)
MY KAD NO.
NATIONALITY CONTACT NUMBER
DATE OF BIRTH AGE SEX MARTIAL STATUS

MALE SINGLE
D D M M Y Y FEMALE MARRIED
ACADEMIC YEAR
PROGRAMME OF STUDY
NEXT OF KIN’S ADDRESS
NEXT OF KIN’S CONTACT NUMBER
PAGE 2 OF 7
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 illness.
* Immediate Family refers to grandparents, father, mother, brothers and sisters.
*IMMEDIATE
SELF
MEDICAL PROBLEMS FAMILY If “yes” please state
Yes No Yes No
1. Congenital or inherited disorder
2. Allergy nose / Allergy skin / Asthma
3. Mental illness / Depression / Anxiety
4. Stroke, other neurological disease
5. Diabetes mellitus
6. Hypertension/High Blood Pressure
7. High cholesterol
8. Heart attack
9. Epilepsy
10. Thyroid
11. Kidney disease
12. Cancer
13. Pulmonary tuberculosis
14. Drug addiction
15. AIDS, HIV
16. History of surgery
17. Lung disease
18. Blackout/fainting/dizzy spells
19. Fits/Convulsion
20. Depression
21. Other illnesses/ disease / Severe
personal injuries
Current long term medication (if any)
PAGE 3 OF 7
IMMUNIZATION HISTORY DATE OF
(where applicable) IMMUNIZATION
1. BCG
2. Hepatitis B
3. Chicken pox
4. Measles, Mumps, Rubella
5. Others:
I hereby certify that the information given above is true. I understand that my application will be
rejected if there is any false information given.
Date Signature of candidate
SECTION 2 - PHYSICAL EXAMINATION

To be filled by examining doctor
1. BASIC MEASUREMENT
HEIGHT : m BLOOD PRESSURE : mmHg
WEIGHT: __________________kg PULSE RATE : ____________/ min
WAIST CIRCUMFERENCE: ______________cm BODY MASS INDEX: ________________kg/m2
SAVISION TEST : Unaided : (R) (L) COLOUR VISION TEST : NORMAL / ABNORMAL
Aided : (R) (L)
2. GENERAL EXAMINATION
ITEM YES NO COMMENT
a. DEFORMITIES
b. PALLOR
c. CYANOSIS
d. JAUNDICE
e. OEDEMA
f. SKIN PROBLEM
PAGE 4 OF 7
3. SYSTEMIC EXAMINATION
ITEM NORMAL ABNORMAL COMMENT
a. EYES
i. Fundus
ii. Squint
b. EARS
i. Any discharge
ii. Tympanic Membrane
iii. Hearing
c. NOSE
i. Sense of Smell
d. RESPIRATION
e. ORAL CAVITY/THROAT
f. NECK
g. HEART
h. LUNGS
i. ABDOMEN / HERNIA ORIFICES
j. NERVOUS SYSTEM
k. MENTAL STATE / 21-DASS score
l. MUSCULOSKELETAL SYSTEM
SECTION 3 – INVESTIGATIONS
URINE TEST
ITEM DATE RESULT

TAKEN
a. ALBUMIN
b. SUGAR
c. MICROSCOPIC
d. MORPHINE
e. CANNABIS
f. AMPHETAMINES TYPE
STIMULANT
g. ALBUMIN
h. SP GRAVITY
i. URINE PREGNANCY TEST
PAGE 5 OF 7
BLOOD TEST
ITEM DATE TAKEN RESULT
a. HEART SOUND
b. RHYTHM
c. MURMUR
HEART TEST
ITEM DATE TAKEN RESULT
a. HEPATITIS B
- ANTIGEN
- ANTIBODY
b. HEPATITIS C ANTIBODY
c. HIV
d. VDRL / TPHA
e. F B C
CHEST EXAMINATION
a. EXPANSION OF THE
CHEST
b. PERCUSSION
c. AUSCULTATION
d. BREAST EXAMINATION
(FOR FEMALE ONLY)
CHEST X-RAY INFORMATION
CHEST X-RAY NO.
DATE TAKEN
PLACE TAKEN
REPORT
PAGE 6 OF 7
SECTION 4- CERTIFICATION BY THE EXAMINATION DOCTOR
Please tick (√) in the appropriate box:
I certify that on this date _____________ that I have examined Ms/Mr
MyKAD No. and found him/her –
FIT TO ATTEND THIS COURSE UNFIT TO ATTEND THIS COURSE
HAVING THE FOLLOWING MEDICAL CONDITION (S):
AND IS UNDERGOING TREATMENT FOR:
Date : Signature of Doctor :
Name of Doctor :
MMC Reg :
Official Stamp :
Remark by College Admission Department:
PAGE 7 OF 7

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HEALTH EXAMINATION GUIDELINES

FOR ENTRY INTO

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:

5. PLEASE COMPLETE ALL THE TESTS REQUIRED IN THIS FORM.

6. THE UNIVERSITY / COLLEGE ONLY ACCEPT MEDICAL EXAMINATION DONE WITHIN 60

7. PLEASE ATTACH ALL THE ORIGINAL LABORATORY RESULTS.

8. PLEASE BRING ALONG CHEST X-RAY REPORT FOR REGISTRATION.

12. THE COLLEGE RESERVES THE RIGHT TO REJECT ANY APPLICATION :-

13. THE COLLEGE RESERVES THE RIGHT TO TERMINATE/EXPEL THE CANDIDATE/STUDENT

HEALTH EXAMINATION REPORT

PLEASE USE CAPITAL LETTERS

SECTION 1 (to be completed by candidate)

FULL NAME (as state in MYKAD)

NATIONALITY CONTACT NUMBER

DATE OF BIRTH AGE SEX MARTIAL STATUS

NEXT OF KIN’S ADDRESS

NEXT OF KIN’S CONTACT NUMBER

Current long term medication (if any)

Date Signature of candidate

SECTION 2 - PHYSICAL EXAMINATION

HEIGHT : m BLOOD PRESSURE : mmHg

WEIGHT: __________________kg PULSE RATE : ____________/ min

WAIST CIRCUMFERENCE: ______________cm BODY MASS INDEX: ________________kg/m2

ITEM YES NO COMMENT

ITEM NORMAL ABNORMAL COMMENT

i. ABDOMEN / HERNIA ORIFICES

k. MENTAL STATE / 21-DASS score

ITEM DATE RESULT

i. URINE PREGNANCY TEST

ITEM DATE TAKEN RESULT

ITEM DATE TAKEN RESULT

CHEST X-RAY INFORMATION

CHEST X-RAY NO.

Please tick (√) in the appropriate box:

I certify that on this date _____________ that I have examined Ms/Mr

MyKAD No. and found him/her –

FIT TO ATTEND THIS COURSE UNFIT TO ATTEND THIS COURSE

HAVING THE FOLLOWING MEDICAL CONDITION (S):

AND IS UNDERGOING TREATMENT FOR:

Date : Signature of Doctor :

Remark by College Admission Department:

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WEIGHT: ______kg PULSE RATE : / min

WAIST CIRCUMFERENCE: cm BODY MASS INDEX: __kg/m2