MEDICAL CHECKUP

  1. Medical Checkup Information

STUDENT INFORMATION

Name null -
Faculty
IC No / Passport No
Status
Address , , ,
Email

MEDICAL CHECKUP INFORMATION

Clinical Finding Lab Result International Student Consultation

CURRENT ILLNESS
No Known Medical Illness
Tuberculosis
Hepatitis B
Hepatitis C
HIV
• Drug use / abuse
        Opiates
        Methamphetamine
        Amphetamine
        Cannabinoids
Congenital or Inherited Disorder
Allergy
Mental Illness
Epilepsy
Stroke / Neurological Disease
Diabetes Mellitus
Hypertension
Heart of Vascular Disease
Asthma
Thyroid Disease
Kidney Diseases
Cancer
History of Surgery
Sexually Transmitted Diseases
History of Blood Transfusion
Other Illness
            This patient was seen by Doctor on .
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