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PANDUAN PENDAFTARAN PELAJAR BAHARU PASCASISWAZAH

STUDENT HEALTH DECLARATION (WITNESSED BY THE DOCTOR)
Please tick (√) in the appropriate box.

1. DISEASES
Have you ever been treated / diagnosed with the following diseases?

Yes No Yes No

Asthma Tuberculosis

Heart Disease High blood pressure

Diabetes Kidney Disease

Fits Mental Illness

Cancer Chronic Skin Disease

Allergy to Medicine/Food Other chronic Disease

If other chronic disease YES, please state :

2. STUDENT DECLARATION*

I, ............................................................................... ID / Passport No...............................

(Name as stated in the ID / Passport)

do hereby declared that all information stated is true.

.................................................. ..................................

(Student Signature) Date

*To be signed witnessed by the Doctor

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