MEDICAL CHECKUP

STUDENT INFORMATION

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

MEDICAL CHECKUP INFORMATION

Clinical Finding Lab Result International Student Consultation

VACCINATION HISTORY

YELLOW FEVER

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BCG

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MENINGITIS (QUADRIVALENT)

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HEPATITIS B

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POLIO

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MEASLES

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RUBELLA

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OTHERS

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MENTAL HEALTH ASSESSMENT

GENERAL APPEARANCE

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SPEECH QUALITY

Coherent

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Relevant

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MOOD

*Depressed

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Anxious

-

Irritable

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AFFECT

Affect

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THOUGHT

Delusion

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Suicidality

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PERCEPTION

Hallucination

-

ORIENTATION

Time

-

Place

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Person

-

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