Spreadsheet: 01e325c6-6611-4f27-bd76-bfd52f1b6b05
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Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12 | Unnamed: 13 | Unnamed: 14 | Unnamed: 15 | Unnamed: 16 | Unnamed: 17 | Unnamed: 18 | Unnamed: 19 | Unnamed: 20 | Unnamed: 21 | Unnamed: 22 | Unnamed: 23 | Unnamed: 24 | Unnamed: 25 | Unnamed: 26 | Unnamed: 27
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Borang PK/03
 |  |  |  |  |  | BORANG PEMERIKSAAN KESIHATAN
 |  |  |  |  |  | BAGI PEGAWAI PERKHIDMATAN AWAM
 |  |  |  |  |  | (SURAT PEKELILING PERKHIDMATAN AWAM BILANGAN 3/2003)
 | A. | BIODATA (Diisi oleh pemohon)
 |  | 1. | [NAME] :
 |  | 2. | No. Kad Pengenalan :
 |  | .3 | Umur : |  |  |  |  |  |  |  |  |  | [NAME] |  |  |  |  |  |  | Bulan (pada tarikh pemeriksaan)
 |  | 4. | [NAME] : |  |  |  |  |  |  |  |  |  | / |  |  | /
 |  | 5. | Jantina |  |  |  |  |  |  |  |  | [NAME] |  |  | Perempuan
 |  | 6. | Bangsa : |  |  |  |  |  |  |  |  | Melayu |  |  | Cina |  |  | India |  |  | Lain-lain, Nyatakan
 |  | 7. | Taraf Perkahwinan : |  |  |  |  |  |  |  |  | Bujang |  |  | Berkahwin |  |  |  | Janda/Duda
 |  | 8. | [NAME] : |  |  |  |  |  |  |  |  |  |  |  | Sek. Rendah |  |  |  |  | SRP |  |  |  | SPM
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | STPM |  |  |  |  | Diploma |  |  |  | Ijazah
 |  | 9. | Alamat Kediaman :
 |  | 10. | Alamat [NAME] :
 |  | 11. | [NAME] (3 yang terkini) :
 |  |  | Nama Jawatan |  |  |  |  |  |  |  |  |  |  | Kementerian |  |  |  |  |  |  |  |  | [NAME]
 |  |  | a.
 |  |  | b.
 |  |  | c.
 |  | 12. | [NAME] :
 |  |  |  | a. | [NAME]
 |  |  |  | b. | Lain-lain (sila nyatakan)
 |  | 13. | [NAME] :
 |  |  | Diagnosis/Jenis Pembedahan |  |  |  |  |  |  |  |  |  |  |  |  |  |  | [NAME]
 |  |  | a.
 |  |  | b.
 |  |  | c.
 |  | 14. | [NAME]
 |  |  |  |  | [NAME]
 |  |  |  |  | [NAME] ([NAME] 6 bulan)
 |  |  |  |  | Perokok
 | Borang Pemeriksaan Kesihatan
 | Bagi Pegawai Perkhidmatan Awam |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Borang PK/03
 |  | 15. | [NAME] (alergi)
 |  |  | i. |  |  | Ubat-Ubatan |  |  |  |  | a. |  |  |  |  |  |  |  |  | b.
 |  |  |  |  |  |  |  |  |  |  | c. |  |  |  |  |  |  |  |  | d.
 |  |  | ii. |  |  | Lain-lain |  |  |  |  | a. |  |  |  |  |  |  |  |  | b.
 |  |  |  |  |  |  |  |  |  |  | c. |  |  |  |  |  |  |  |  | d.
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | [NAME]
 |  | 16. | [NAME]
 |  |  | a. |  |  | [NAME]
 |  |  | b. |  |  | Kanser
 |  |  | c. |  |  | Diabetes Melitus
 |  |  | d. |  |  | Hipertensi (DarahTinggi)
 |  |  | e. |  |  | Strok (Angin Ahmar)
 |  |  | f. |  |  | [NAME]
 |  |  | g. |  |  | Lain-lain (sila nyatakan)
 | B. | PEMERIKSAAN FIZIKAL
 |  | 1. | Tinggi : |  |  |  |  |  |  | m |  |  |  | Berat Badan : |  |  |  |  |  |  |  |  | [NAME]
 |  | 2. | Indeks [NAME] (BMI) : |  |  |  |  |  |  |  |  | kg/m2 |  |  |  |  |  | BMI < 18 (Kurang Berat Badan)
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | BMI 18 - 23 (Normal)
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | BMI 23 - 30 (Lebih Berat Badan)
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | BMI > 30 (Kegemukan/Obes)
 |  | 3. | Penglihatan : |  |  |  |  |  | 6 / |  | [NAME] |  |  |  |  |  | 6 / |  | Kiri (Tanpa Cermin Mata)
 |  |  |  |  |  |  |  |  | 6 / |  | [NAME] |  |  |  |  |  | 6 / |  | Kiri (Dengan Cermin Mata)
 |  | 4. | [NAME] : |  |  |  |  |  |  |  |  |  | / | min |  |  | [NAME] ([NAME]) :
 |  | 5. | [NAME] (BP) : |  |  |  |  |  |  |  |  |  | [NAME] / Hg
 |  |  |  |  |  |  |  |  |  |  |  |  | [NAME]
 |  | 6. | Pemeriksaan [NAME] Payudara : Normal / Tidak Normal :
 |  | 7. | Pap Smear :
 |  | 8. | Lain-lain pemeriksaan [NAME] :
 | C. | UJIAN MAKMAL
 |  | 1. |  |  | [NAME] :
 |  |  |  |  |  |  |  |  | Rawak (Random) |  |  |  |  |  |  |  |  |  |  |  |  | mmol/l
 |  |  |  |  |  | atau
 |  |  |  |  |  |  |  |  | Puasa (Fasting) |  |  |  |  |  |  |  |  |  |  |  |  | mmol/l
 |  | 2. |  |  | Lipid Serum :
 |  |  |  |  |  |  |  |  | Total Cholesterol |  |  |  |  |  |  |  |  |  |  |  |  | mmol/l
 |  |  |  |  | Nota : Jalankan ujian lanjut jika diperlukan.
 | Borang Pemeriksaan Kesihatan
 | Bagi Pegawai Perkhidmatan Awam |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 2
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | [NAME]
SURAT PENGESAHAN PEMERIKSAAN KESIHATAN
 |  | [NAME] disahkan bahawa [NAME] dibawah telah menjalankan pemeriksaan [NAME] perlu /
 |  | tidak perlu* mendapatkan rawatan lanjut :
 |  |  |  | NAMA :
 |  |  |  | NO. KAD PENGENALAN :
 |  |  |  | UMUR :
 |  |  |  | JAWATAN :
 |  |  |  | Tarikh : |  |  |  |  |  |  |  |  |  |  |  | Masa :
 |  |  |  | [NAME] :
 |  |  |  | [NAME] :
 |  |  |  | (* potong mana yang tidak berkenaan)
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Lampiran A
BORANG PERMOHONAN
PEMERIKSAAN KESIHATAN
(Disediakan dalam 2 salinan)
 |  | A. | MAKLUMAT PEGAWAI
 |  |  | Nama |  |  |  |  |  | :
 |  |  | Tarikh Lahir / Umur |  |  |  |  |  | :
 |  |  | Jawatan |  |  |  |  |  | :
 |  |  | [NAME] |  |  |  |  |  | :
 |  |  | [NAME] |  |  |  |  |  | :
 |  |  | Tarikh |  |  |  |  |  | :
 |  | B. | [NAME]
 |  |  | [NAME] disahkan [NAME] mendapat [NAME] pemeriksaan Kesihatan di bawah Pekeliling Perkhidmatan
 |  |  | Bil : 3 Tahun 2003
 |  |  | [NAME] |  |  |  |  |  | :
 |  |  | Nama |  |  |  |  |  | :
 |  |  | Jawatan |  |  |  |  |  | :
 |  |  | Tarikh |  |  |  |  |  | :
 |  |  | Cop Jabatan |  |  |  |  |  | :