HEALTH EXAMINATION GUIDELINES FOR STUDENT PASS / DEPENDANT PASS ISSUANCE IN MALAYSIA
(Required by the Government of Malaysia)
1. 2. 3. PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE FILLING IN THE FORM. PLEASE FILL IN THE FORM IN THE ENGLISH LANGUAGE. PLEASE WRITE IN CAPITAL LETTERS.
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THIS FORM HAS 4 SECTIONS:
(a) SECTION 1 (PART A AND B) TO BE COMPLETED BY THE APPLICANT & ALL FIELDS ARE MANDATORY; AND (b) SECTION 2, 3 AND 4 TO BE COMPLETED BY THE EXAMINING DOCTOR AT THE CLINIC/HOSPITAL DULY APPOINTED BY EMGS
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PLEASE COMPLETE ALL THE TESTS REQUIRED IN THIS FORM. MEDICAL EXAMINATIONS REPORT COMPLETION AND SUBMISSION REQUIREMENTS THIS REPORT MUST TO BE COMPLETED WITHIN 7 WORKING DAYS FROM THE DATE OF ENTRY FOR ONWARDS SUBMISSION OF COMPLETE REPORT TO EMGS BY THE CLINIC/HOSPITAL WITHIN 4 WORKING DAYS THEREAFTER.
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PLEASE ENSURE THE CHEST X-RAY FILM IS LABELLED WITH YOUR NAME AND DATE TAKEN (IN ENGLISH). EMGS RESERVES THE RIGHT TO REQUEST FOR A REPEAT COMPLETE 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 STUDENTS AND THE DEPENDANTS. IN THE EVENT OF FAILING THE MEDICAL EXAMINATION, NO REFUND IS PAYABLE. THE RESULTS OF THE HEALTH EXAMINATION WILL BE USED BY EMGS AND/OR THE EMGS APPOINTED INSURANCE COMPANIES IN CONCLUDING THE HEALTH INSURANCE COVERAGE WHICH HAS BEEN CONDITIONALLY OFFERED TO STUDENT/DEPENDANT WITH EFFECT FROM THE DATE OF ENTRY, SUBJECT TO REVIEW AND ACCEPTANCE OF THIS HEALTH EXAMINATION REPORT. EMGS AND/OR THE EMGS APPOINTED INSURANCE COMPANIES RESERVE THE RIGHT TO REVOKE THE HEALTH INSURANCE CONDITIONALLY OFFERED TO STUDENT OR DEPENDANT IF THERE IS EVIDENCE THAT THE STUDENT/DEPENDANT HAS GIVEN FALSE INFORMATION IN THE HEALTH EXAMINATION REPORT OR ANY SUPPORTING DOCUMENTS. THIS MAY ALSO TRIGGER THE REVOCATION OF STUDENT/DEPENDANT PASS/VISA ISSUED BY THE IMMIGRATION OF MALAYSIA.
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HEALTH EXAMINATION REPORT FOR INTERNATIONAL STUDENTS/DEPENDANTS Passport size photo
IMPORTANT: PLEASE USE CAPITAL LETTERS
SECTION 1 (To be completed by APPLICANT and all fields are MANDATORY)
(PART A)
FULL NAME (AS IN PASSPORT)
INTERNATIONAL PASSPORT NUMBER
NATIONALITY
CONTACT NUMBER IN MALAYSIA
EMAIL ADDRESS
DATE OF BIRTH D D M M Y Y
AGE
SEX MALE FEMALE
MARITAL STATUS SINGLE MARRIED
CORESPONDING ADDRESS IN MALAYSIA
ACADEMIC YEAR
MONTH
COURSE AND ACADEMIC DEPARTMENT / SCHOOL
NEXT OF KIN
NEXT OF KINS ADDRESS
NEXT OF KINS CONTACT NUMBER
SECTION 1 (PART B) Please tick ( ) in the relevant box.
Declaration of self and family illness. ness. Explain in full if you or your immediate* family has any of the following illnesses. * Immediate family refers to father, mother, brothers / sisters
SELF Yes
1. 2. 3. 4. 5. 6. Congenital or inherited disorder Allergy Mental illness Fits, stroke, other neurological dis sease Diabetes Mellitus Hypertension
MEDICAL HISTORY
IMMEDIATE FAMILY Yes No
If Yes please plea state details
No
7. Heart or vascular disease 8. 9. Asthma Thyroid disease
10. Kidney disease 11. Cancer 12. Tuberculosis 13. Drug addiction 14. AIDS, HIV 15. History of surgery 16. Other illnesses
If on any medication, on, please state below: below
IMMUNISATION HISTORY (where applicable) 1. Yellow Fever 2. BCG 3. Meningitis (Quadrivalent) 4. Hepatitis B 5. Others:
Yes
No
Date of last immunization
I hereby certify that the information given above is true. I understand that my application ap will be rejected if there is any false information given.
Date: 3
Signature of student/dependant
SECTION 2 - PHYSICAL EXAMINATION (To be completed by EXAMINING DOCTOR) EMGS Reference Number:
Has the Consent Letter been signed by the foreign student/dependant? Has the Letter of Undertaking been signed by the foreign student/dependant?
1. GENERAL EXAMINATION HEIGHT : WEIGHT: PULSE RATE: m kg per minute BLOOD PRESSURE SYSTOLIC: DIASTOLIC: mmHg mmHg
YES / NO YES / NO
VISION TEST Normal Unaided Aided L R L R Defective
COLOUR VISION TEST: NORMAL / ABNORMAL
2. GENERAL EXAMINATION ITEM a. DEFORMITIES b. PALLOR/ANAEMIA c. CYANOSIS d. JAUNDICE e. OEDEMA f. SKIN DISEASES YES NO COMMENT
3. SYSTEMIC EXAMINATION ITEM a. EYES (including funduscopy) b. EARS/HEARING ABILITY c. NOSE d. ORAL CAVITY / THROAT e. NECK f. HEART g. LUNGS h. ABDOMEN / HERNIA ORIFICES i. j. NERVOUS SYSTEM MENTAL STATUS NORMAL ABNORMAL COMMENT
k. MUSCULOSKELETAL SYSTEM L. ANAESTHETIC SKIN PATCH m. LYMPH NODE ENLARGEMENT n. GENITOURINARY SYSTEM
SECTION 3 - MEDICAL EXAMINATIONS (To be completed by EXAMINING DOCTOR)
URINE TEST ITEM POSITIVE/ ABNORMAL a. ALBUMIN b. SUGAR c. MICROSCOPIC EXAMINATION d. MORPHINE e. CANNABIS f. AMPHETAMINE-TYPE STIMULANT NEGATIVE/ NORMAL COMMENT
BLOOD TEST ITEM a. HEPATITIS Bs ANTIGEN b. HEPATITIS C ANTIBODY c. HIV d. VDRL / TPHA e. MALARIA PARASITE f. S E R U M C R E A T I N I N E POSITIVE/ ABNORMAL NEGATIVE/ NORMAL COMMENT
CHEST X-RAY INFORMATION CHEST X-RAY NO. DATE TAKEN PLACE TAKEN Comments (if any) DESCRIPTION 1. Thoracic cage 2. Heart shape and size (CTR if applicable) 3. Lung fields 4. Mediastinum and hila 5. Pleura/Hemidiaphragms/Costophrenic Angles 6. Focal Lesion (e.g: old/new PTB, malignancy) 7. Any other abnormalities 8. Impression NORMAL ABNORMAL
SECTION 4 - CERTIFICATION BY THE EXAMINING DOCTOR Please tick () in the appropriate box
I certify that I have on this date . examined Mr / Ms Passport No. .. and
EMGSs Reference No . and in my opinion, the applicant: IS IN GOOD HEALTH AND SUITABLE TO STUDY OR TO RESIDE IN MALAYSIA
IS NOT IN GOOD HEALTH BUT CAN BE CERTIFIED SUITABLE TO STUDY OR TO RESIDE IN MALAYSIA as he/she has given the undertaking to undergo the relevant medical treatment at his/her own cost for (Please state)
For record purposes: I have on date ______________________communicated to the Applicant [ with his/her presence at the clinic OR via phone call ]* of his/her medical conditions and the required medical treatment. The Applicant has confirmed to choose to remain in Malaysia and he/she has given the abovementioned undertaking. * Delete as appropriate IS NOT IN GOOD HEALTH AND/OR UNSUITABLE TO STUDY OR TO RESIDE IN MALAYSIA due to (Please state)
Date :
Signature of Doctor Name of Doctor Qualification Hospital / Clinic Registration Number Official stamp
: : : : :
Note: In completing this form, particular attention should be paid to the following points: i. In the event of the albumin level being 3+ from the urine test, the laboratory and the examining doctor shall ensure that a further blood test be conducted to test for abnormal serum creatinine levels prior to the examining doctor concluding whether the student or dependant is suitable to study and/or to reside in Malaysia. The conclusion shall only be drawn after taking into consideration the guidelines issued by MOHE/MOH as communicated by EMGS.
ii.
FOR INTERNAL USE ONLY (TO BE COMPLETED BY EMGS)
(A)
st
Review of MER
1 Level Review Completed by: Date:
nd
Proposed conclusion:
MER Satisfactory, pending 2
Level review
nd
MER Unsatisfactory, pending 2
Level review
Remarks (if any):
nd
Level Review Date:
Completed by:
Conclusion:
MER - Satisfactory
MER - Unsatisfactory Remarks (if any):
(B)
Audit Review Date:
Completed by: Remarks (if any):
