Pusat Pengajian Siswazah | Graduate School

UniSZA-PT01-PK02-BR001G-S01

Report of Medical Examination (For Local Student)

Part A : To be completed by the candidate

1. Full Name

M O H D N I Z A M U D I N B I N
M O H D P A U Z I

2. Identity Card No. - -

8 9 0 7 0 9 0 3 5 5 7 5

3. Passport No.

4. Date of Birth
0 9 0 7 1 9 8 9

5. Sex Male / Female

6. Race Malay / Chinese Indian Other

7. Nationality
MALAYSIAN

8. Marital Status Single Married /

9. Current correspondence address

N 0 3 0 6 B L O K A 1
O
S E K S Y E N 1 0

Postcode City
5 3 3 0 0 WANGSA MAJU

State W.P KUALA LUMPUR

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10. Have you or has any member of your family ever had any serious illness or surgical
operation?
YES

11. Have you or has any member of your family are been under treatment of tuberculosis?

NO

12. Have you or any member of your family ever suffered from mentel diseases, fits or
epilepsy, or been treated in an institution for any kind of these diseases?

NO

(I hereby certify that the information supplied by me to the Medical Examiner is correct.)
[Signature of the candidate must be made in the presence of the Medical Examine]

6 MAC 2020
Signature of Student Date

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Part B : To be completed by physician

State if “Normal”, if not, give particulars of any departure from normal:

1. Heart

2. Blood Pressure Max. Min.

3. Lungs

4. Nervous System

5. Mental Condition and Intelligence

6. Digestive Organs

7. Skeleton-Bones and Joints

8. Skin

9. Cause of Defect of Sight

10. Hearing

11. Genito Urinary Organs

12. Urine- is Albumin of Sugar Present?

13. Urine Morphine/ Heroin Derivatives Test

(To Be Submitted When Ready)

14. Teeth

15. Deforminities

16. Weight

17. Height

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18. Mantoux Test (Date and Results, if Done)

19. B.D.G (Date of Inoculation, if Done)

20. Chest X-ray Report (The Examination Should Have Made Within the Last Two Months)

21. H.I.V

Remarks: In cases where the Medical Examiner is unable to describe the examinee as being in
perfect health and development, he should state the exact nature of the defect which he finds
and whether it is of a permanent or temporary nature.

I certify that I have this day examined the above named that the results are set forth, and I
certify that in my opinion, subject to any special observations under “Remarks” above name is in
good health and of sound constitution, and not suffering from any mental or bodily defect which
is likely to render him unfit to pursue or to complete his graduate studies at Universiti Sultan
Zainal Abidin.

Date

Address

Signature and Qualification