Health Examination Guidelines
For Entry Into
Universiti Tunku Abdul Rahman
1.
Read the instructions carefully before filling in the form.
2.
The form has 4 sections:
(a)
Section 1 (Parts A and B) to be filled by the candidate; and
(b)
Sections 2, 3 and 4 to be filled by the examining doctor. Please complete all the
tests required in this form.
3.
The university only accepts medical examination done within 60 days before
registration or within 30 days after registration.
4.
Attach all original laboratory result.
5.
Chest x-ray done within 6 months prior to registration can be accepted.
6.
Please keep the chest x-ray film for future verification, if required.
7.
The university reserves the right to request 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.
8.
Before submission please make a photocopy of the Health Examination Report and all
documents pertaining to the Health Examination for your own reference.
9.
This page will be returned to you after it has been acknowledged receipt by a staff of
the University.
Student’s Name:
NRIC No.:
Student’s Signature:
Received By:
Staff’s Name:
Department/Faculty:
Date Received:
Universiti Tunku Abdul Rahman
Form Title: HEALTH EXAMINATION REPORT
Form Number: FM-DACE-014
Rev No. : 0
Effective Date: 01/01/2011
Page No: 1 of 5
PLEASE USE CAPITAL LETTERS
Passport size
photo
SECTION 1 (To be completed by candidate)
(PART A)
FULL NAME: _______________________________
REGISTRATION NO.: ________________
CONTACT NUMBER: ________________________
DATE OF BIRTH: ___________________
MARITAL STATUS: SINGLE* / MARRIED*
GENDER: MALE* / FEMALE*
PROGRAMME OF STUDY: __________________________________________________________
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