UCSI University
International application / 国际申请Health Declaration / 健康声明

Health Declaration Form 为自我筛查表格，完成下面内容填写后就会获得一张完整的健康自检表。

01

Health checklist / 健康项目

Declare each condition / 逐项申报健康状况

I hereby declare that I am free from the following diseases/conditions.本人在此声明没有以下疾病或健康状况。
Tuberculosis结核病
Leprosy麻风病
Hepatitis B乙型肝炎
Hepatitis C丙型肝炎
HIV人类免疫缺陷病毒（HIV）
Drug use/abuse: Opiates药物使用或滥用：阿片类
Drug use/abuse: Cannabinoids药物使用或滥用：大麻素类
Drug use/abuse: Amphetamine药物使用或滥用：苯丙胺
Drug use/abuse: Methamphetamine药物使用或滥用：甲基苯丙胺
Sexually Transmitted Diseases性传播疾病
Congenital or Inherited Disorder先天性或遗传性疾病
Cancer癌症
Epilepsy癫痫
Psychiatric Illness精神疾病
Other illness其他疾病
02

Applicant details / 申请人资料

Match the passport / 与护照信息一致

03

Applicant’s signature / 申请人签名

Read, then sign / 阅读后签名

Not signed / 未签名
Your information stays on this device. / 您的信息保留在本设备。

The PDF is completed in your browser and downloaded locally. Nothing entered here is submitted to the server. / PDF 在浏览器中生成并下载到本地，本页填写的信息不会提交至服务器。

READY TO EXPORT / 准备导出

Download the completed original form. / 下载填写完成的原版表格。

健康自检表下载[空表]

DECLARATION

Please read before signing

5

I declare that I will submit myself for compulsory Post-Arrival Health Examination as per Malaysian regulations. In the event that I should be diagnosed with any condition that deems me UNSUITABLE for studies, I will bear the cost of leaving Malaysia and will adhere to the immigration requirements on the visit pass and exit before the pass expiration, or any deadline given to me whichever is earlier.

I declare that in the event I should be diagnosed with any conditions that does not require my removal from Malaysia but requires medical treatment and I choose to remain in Malaysia to continue my studies, I will bear any and all costs relating directly or indirectly towards the medical management of my medical condition.

I confirm that EMGS Panel Clinic/University Health Centre shall not be responsible in any manner or whatsoever, arising out of EMGS Panel Clinic/University Health Centre certification of my medical status as suitable to study or reside in Malaysia despite the medical condition described above. I further undertake to hold EMGS Panel Clinic/University Health Centre harmless from any loss or liability arising from this decision and agree to indemnify and keep EMGS Panel Clinic/University Health Centre from any loss or liability arising from this decision.

Please read for 5 seconds / 请阅读 5 秒

SIGNATURE PAD / 签名板

Sign with pen / 手写签名

Draw inside the box using a mouse, trackpad, finger or stylus. / 请使用鼠标、触控板、手指或触控笔在框内签名。