Student Medical Record Form
KYS Student Affairs • For KYS Nurse / KYSSA Officer Use Only
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Student ID
Lookup
Date & Time of Visit
—
Full Name
MyKad Number
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Form
House
Gender
Location of Treatment
Clinic / Polyclinic (if applicable)
In-house Treatment
Klinik Aafiyah, Batu Berendam
Klinik Impian, Durian Tunggal
Klinik Kesihatan, Durian Tunggal
Klinik One Medic, Gangsa
Klinik Vista, Durian Tunggal
Poliklinik Al-Amin, Ayer Keroh
Poliklinik Wahidah, Ayer Keroh
Dental Clinic (if applicable)
Klinik Pergigian Sharlindah, MITC
Klinik Pergigian Kaunsar, Durian Tunggal
Hospital (if applicable)
Hospital Pantai, Ayer Keroh
Hospital Putra, Pengkalan Rama
Hospital Besar Melaka
Diagnosis
Remarks / Treatment Given
Attended By (Doctor / Medical Personnel)
KYS Nurse / KYSSA Officer Name
Select nurse / officer...
SN Haryani
SN Suhana
SN Nadirah
Warden Azi Azura bt. Arzunaidi
Warden Airme bin Kaba
Warden Mohd Rodi bin Mat Lazim
Warden Muhammad Zaki bin Mazlan
Warden Nurul Hajar binti Mazlan
Warden Noor Ain binti Ibrahim
AHM Abdul Rashid bin Azhar
AHM Muhammad Nazirul bin Rahim
AHM Hammad Haziq bin Ismail
AHMs Munirah Atirah binti Muhamed Asli
AHMs Nur Siti Zakirah binti Mohd Radzani
AHMs Wan Nuur Emilia Emyra binti Anuar
Other
KYS Nurse / KYSSA Officer Signature
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KYS STUDENT MEDICAL RECORD
Kolej Yayasan Saad Melaka • Student Affairs Department (KYSSA)
Student Details
Student ID
Name
MyKad
Form
House
Gender
Visit Details
Date
Day
Time
Location
Diagnosis
Remarks / Treatment Given
Attending Personnel
Attended By
KYS Nurse / KYSSA Officer
Signature
