MEDICAL CERTIFICATE

MEDICAL REPORT TO APPLY FOR COLOMBO PLAN LONG-TERM

SCHOLARSHIP PROGRAMME

Post Graduate Course Applied: ______________________________________________________

1. Name of Applicant : 2. Age : .........................

3. Family History : ...

...

4. Personal History: Details of important illness, accident or operation should be given together
with subsequent treatment particular should be made concerning any form of tuberculosis,
rheumatic fever, cholera, fever, dyspepsia, epilepsy, diabetes, nervous or mental illness and
known allergies.

5. Present Condition:
a. Height : ................... ........... d. Vaccination : .......................
b. Weight : .............................. e. Tuberculin test result : .....................
c. Physique : ............................. f. Blood group : ......................

6. Respiratory System:
a. Nose : .................. d. Pharynx : ................................
b. Chest Expansion : ................. ... e. Lungs (R & L) : ...............................
c. Complete X - ray : ..................
Report of the chest : ..................

Film No.: .................... Hospital: ..................................... Date: ..........................

7. Circulatory System:
a. Pulse : ..................
b. Blood Pressure : ..................
c. Heart : ..................

8. Alimentary System:
a. Appetite : .................. f. Digestion : ..................
b. Bowels : .................. g. Teeth : ..................
c. Tongue : .................. h. Spleen : ..................
d. Liver : .................. i. Rupture : ..................
e. Haemorrhoids : ..................

9. Nervous System:
a. Temperament : .................. c. Reflexes : ..................
b. Hearing : .................. d. Sight : ..................

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10. Reproductive System:
a. Varicose : .................. c. Syphilis : ..................
b. Gonorrhoea : ..................

11. Urinary System:

a. Specific Gravity : .................. d. Deposits : ..................
b. Sugar : .................. e. Miscellaneous : ..................
c. Albumin : ..................

12. Is the candidate at present:

a. Undergoing a treatment : Yes/ No
b. Receiving medical attention : Yes/ No
c. Requiring medical attention: If so please give details
________________________________________________________________
________________________________________________________________
________________________________________________________________

I certify that the above candidate is medically fit to undertake a course in Malaysia.

Signature of Physician : __________________________________ Date: ____________________

Name :________________________________
Address :________________________________
________________________________

13. Certification from Nominating Agency:

I certify that the candidate has been medically examined by a qualified and registered medical
practitioner.

Signature : _________________________________
Name : _________________________________
Rank/ Title: _________________________________
Agency : _________________________________

Seal of Nominating Agency : ____________________

Note: In completing this form, particular attention should be paid to the following points:

a. X-ray of chest to rule out any tuberculosis or chronic pulmonary disease.

b. Kidneys no evidence of renal lesion should be present.
c. Eyesight Severe errors of refraction should not be passed as these would give difficulties in
the training.
d. Hearing deafness would possibly be considered a disqualifying.