فرم تست پزشکی برای دریافت ویزای تحصیلی مالزی
فرم تست پزشکی برای دریافت ویزای تحصیلی مالزی
برای دریافت ویزای تحصیلی از سفارت مالزی در ایران باید فرم تست پزشکی که نشان از وضعیت درخواست کننده ویزا است را تکمیل و ارائه کنید. این کار باید توسط پزشک انجام شود
در زیر فایل و خلاصه ای از این فرم را به صورت انگلیسی مشاهده می فرمایید
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فرم تست پزشکی برای دریافت ویزای تحصیلی مالزی
| HEALTH EXAMINATION GUIDELINES
FOR ENTRY INTO MALAYSIAN HIGHER EDUCATIONAL INSTITUTIONS |
|
| ۱٫ | PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE FILLING IN THE FORM. |
| ۲٫ | PLEASE FILL IN THE FORM IN ENGLISH LANGUAGE. |
| ۳٫ | PLEASE WRITE IN CAPITAL LETTERS. |
| ۴٫ | THIS FORM HAS 4 SECTIONS:
a) SECTION 1 (PART A AND B) TO BE FILLED BY THE APPLICANT; AND b) SECTION 2,3 AND 4 TO BE FILLED BY THE EXAMINING DOCTOR |
| ۵٫ | PLEASE COMPLETE THE ENTIRE TEST REQUIRED IN THIS FORM. |
| ۶٫ | THE UNIVERSITY / COLLEGE ONLY ACCEPT MEDICAL EXAMINATION DONE WITHIN 90 DAYS BEFORE ARRIVAL IN MALAYSIA. |
| ۷٫ | PLEASE ATTACH ALL THE ORIGINAL LABORATORY RESULTS. |
| ۸٫ | PLEASE BRING ALONG CHEST X-RAY FILM (OR DIGITAL IMAGES) AND REPORT FOR REGISTRATION, FOR THE PURPOSE OF VERIFICATION, IF NECESSARY. |
| ۹٫ | PLEASE ENSURE THE X-RAY FILMS OR DIGITAL IMAGES ARE LABELLED WITH YOUR NAME AND DATE TAKEN (IN ENGLISH). |
| ۱۰٫ | CHEST X-RAY DONE WITHIN 6 MONTHS PRIOR TO REGISTRATION CAN BE ACCEPTED. |
| ۱۱٫ | THE UNIVERSITY / COLLEGE 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. |
| ۱۲٫ | THE UNIVERSITY / 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. |
HEALTH EXAMINATION REPORT FOR INTERNATIONAL STUDENTS
SECTION 1 (PART A)
FULL NAME (AS IN PASSPORT)
INTERNATIONAL PASSPORT NUMBER BLOOD GROUP (RHESUS)
NATIONALITY CONTACT NUMBER IN MALAYSIA
DATE OF BIRTH AGE SEX MARITAL STATUS
ACADEMIC YEAR STUDENT ID
NEXT OF KIN
The details of the blood type recorded here are as reported by the patient and have not been tested or verified to be correct by the medical practitioner completing this online medical screening questionnaire. The medical practitioner completing this form disclaims any and all liability to the fullest extent permitted by law for any personal injury, suffering or loss caused by any reliance on this information by any other party.
HEALTH EXAMINATION REPORT FOR INTERNATIONAL STUDENTS
SECTION 1 (PART B)
Declaration of self and family illness. Explain in full if you or your immediate* family has any of the following illnesses. * Immediate family refers to mother, brothers / sisters.
| MEDICAL PROBLEMS | SELF | IMMEDIATE FAMILY | If “Yes” please state details | ||
| Yes | No | Yes | No | ||
| ۱٫ Congenital or Inherited Disorder | |||||
| ۲٫ Allergy | |||||
| ۳٫ Mental Illness | |||||
| ۴٫ Fits, Stroke, Other Neurological Disease | |||||
| ۵٫ Diabetes Mellitus | |||||
| ۶٫ Hypertension | |||||
| ۷٫ Heart or Vascular Disease | |||||
| ۸٫ Asthma | |||||
| ۹٫ Thyroid Disease | |||||
| ۱۰٫ Kidney Disease | |||||
| ۱۱٫ Cancer | |||||
| ۱۲٫ History of Surgery | |||||
| ۱۳٫ Tuberculosis (TB) | |||||
| ۱۴٫ HIV / AIDS | |||||
| ۱۵٫ Hepatitis B | |||||
| ۱۶٫ Sexually Transmitted Diseases | |||||
| ۱۷٫ Drug Addiction | |||||
| ۱۸٫ Other Illnesses | |||||
- *A valid Yellow Fever vaccination certificate is required from all travellers coming from or transited more than 12 hours through countries with risk of Yellow Fever transmission.
- All students are required to take vaccines as listed in numbers 2-7 above.
- The students are required to bring along the International Certificate of Vaccination or Prophylaxis with them for verification of information.
HEALTH EXAMINATION REPORT FOR INTERNATIONAL STUDENTS
SECTION 2 – PHYSICAL EXAMINATION
BLOOD PRESSURE:
HEIGHT (m) : WEIGHT (kg) BMI(kg/m²) PULSE RATE
VISION TEST
UNAIDED (L)
UNAIDED (R)
AIDED (L)
AIDED (R)
HEARING ABILITY
LEFT
RIGHT
- GENERAL EXAMINATION
| ITEM | YES / ABNORMAL | NO / NORMAL | COMMENT |
| a. DEFORMITIES | |||
| b. PALLOR | |||
| c. CYANOSIS | |||
| d. JAUNDICE | |||
| e. OEDEMA | |||
| f . SKIN DISEASES |
- SYSTEMIC EXAMINATION
| ITEM | NORMAL | ABNORMAL | COMMENT |
| g. EYES (including funduscopy) | |||
| h. EARS | |||
| i. NOSE | |||
| j. ORAL CAVITY / THROAT | |||
| k. NECK | |||
| l. CARDIOVASCULAR SYSTEM | |||
| m. RESPIRATORY SYSTEM | |||
| n. ABDOMEN/HERNIAL ORIFICES | |||
| o. NERVOUS SYSTEM | |||
| p. MENTAL STATUS | |||
| q. MUSCULOSKELETAL SYSTEM |
HEALTH EXAMINATION REPORT FOR INTERNATIONAL STUDENTS
SECTION 3 – LABORATORY RESULTS
| URINE TEST | ||||
| ITEM | POSITIVE / ABNORMAL | NEGATIVE / NORMAL | COMMENT | |
| a. ALBUMIN | ||||
| b. SUGAR | ||||
| c. MICROSCOPIC EXAMINATION | ||||
| d. OPIATES (INCLUDING CODEINE,
MORPHINE, HEROIN) |
||||
| e. CANNABINOIDS | ||||
| f. AMPHETAMINE TYPE STIMULANT | ||||
| BLOOD TEST | ||||
| ITEM | POSITIVE / ABNORMAL | NEGATIVE / NORMAL | COMMENT | |
| a. HEPATITIS Bs ANTIGEN | ||||
| b. HIV | ||||
| c. VDRL | ||||
| d. TPHA | ||||
| e. MALARIAL PARASITES |
* TPHA is done if VDRL is reactive
** all test results / reports is valid for 6 months
HEALTH EXAMINATION REPORT FOR INTERNATIONAL STUDENTS SECTION 4 – CHEST X-RAY FINDINGS
| ITEM | NORMAL | ||
| THORACIC CAGE | |||
| HEART SHAPE AND SIZE CTR IF APPLICABLE) | |||
| LUNG FIELDS | |||
| MEDIASTHNUM AND HILA | |||
| PLEURA / HEMIDIAPHRAGMS / COSTOPHRENIC ANGLES | |||
| FOCAL LESION | |||
| ANY OTHER ABNORMALITIES | |||
| IMPRESSION |
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HEALTH EXAMINATION REPORT FOR INTERNATIONAL STUDENTS
SECTION 5 – CERTIFICATION BY THE EXAMINING DOCTOR
| ITEM | ABNORMAL |
| HIV | |
| HEPATITIS B | |
| TUBERCULOSIS | |
| MALARIA | |
| TYPHOID | |
| SEXUALLY TRANSMITTED DISEASES | |
| CANCER | |
| EPILEPSY | |
| PSYCHIATRIC ILLNESS
HIS/HER URINE CONTAINS OPIATES |
|
| HIS/HER URINE CONTAINS CANNABINOIDS | |
| HIS/HER URINE CONTAINS AMPHETAMINE | |
| EBOLA | |
| OTHERS | |
HEREBY THE STUDENT IS CERTIFIED AS
SUITABLE UNSUITABLE
FOR STUDY IN MALAYSIA.
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