KUMPULAN WANG SIMPANAN PEKERJA

LAPORAN PERUBATAN MENGENAI PESAKIT UNTUK PENGELUARAN KESIHATAN KWSP

Laporan perubatan ini disediakan oleh doktor yang merawat pesakit untuk menentukan tahap
kesihatan pesakit bagi pihak KWSP. Laporan ini diperlukan bagi memenuhi syarat di bawah Skim
Pengeluaran Kesihatan KWSP.

1. NAMA PESAKIT
PATIENT’S NAME

2. NO. PENDAFTARAN PESAKIT

PATIENT’S REGISTRATION NO.

3. TARIKH MASUK HOSPITAL (Jika ada)

DATE OF ADMISSION (If any)

4. TARIKH KELUAR HOSPITAL (Jika ada)

DATE OF DISCHARGE (If any)

5. TARIKH KEMATIAN (Jika ada)

DATE OF DEATH (If any)

6. NO. KP 12 DIGIT / NO. SURAT

BERANAK/NO. PASPORT
12 DIGIT NRIC NO. /
BIRTH CERTIFIICATE NO./PASSPORT NO.
7. UMUR / JANTINA
LELAKI / PEREMPUAN /
AGE / GENDER
MALE FEMALE

8. PENYAKIT YANG DIHIDAPI / ILLNESS

Sila tandakan (x) pada ruangan yang disediakan / Please indicate (x) below

KATEGORI/JENIS PENYAKIT KRITIKAL KATEGORI/JENIS PENYAKIT KRITIKAL

CANCER NERVOUS SYSTEM
Cancer Alzheimer’s Disease
Appalic Syndrome
CARDIOVASCULAR SYSTEM Benign Tumor Of Brain
Cerebral Palsy
Arrhythmia Requiring Device Insertion (Pacemaker/Defibrillator) Coma
Cardiomyopathy/Heart Failure Encephalitis
Congenital Heart Disease Loss Of Speech
Constrictive Pericarditis Major Head Trauma
Coronary Artery Disease/Ischaemic Heart Disease Meningitis
Motor Neurone Disease
Heart Attack / Myocardial Infarction
Heart Block Requiring Surgical Intervention/Pacemaker/Battery Multiple Sclerosis
Implant Muscular Dystrophy
Heart Valve Replacement / Valvular Heart Disease Requiring Paralysis
Replacement Parkinson’s Disease
Poliomyelitis
Peripheral Vascular Disease
Stroke
Surgery to Aorta / Diseases of the Aorta Requiring Surgery Total Permanent Disability

ENDOCRINE/MEDICAL OPHTHALMOLOGY
(Sila penuhkan juga Ruangan 9/Please also complete paragraph 9)
Epilepsy & Movement Disorders Requiring Deep Brain Stimulation Or Advanced Diabetic Eye Disease - Diagnose By Specialist
Surgery Age Related Macular Degeneration (Armd)/Polypoidal Choroidal
Guillain Barre Syndrome Requiring Immunoglobulin Treatment Vasculopathy (PCV)
Morbid Obesity Or Obesity With Multiple Medical Complications And Blindness
Life Threatening Requiring Bariatric Surgery Cataract Requiring Surgery (Intraocular Lens – IOL)
Pituitary Tumors Corneal Disorders Requiring Corneal Surgery (Corneal Transplant) –
Sepsis With One Or More Major Organ Failure Diagnose By Specialist
Type 1 Diabetes With Criteria For Insulin Pump Therapy Enopthalmic Socket - Diagnose By Specialist
Glaucoma Requiring Surgery With Glaucoma Implant
Retinal Vascular Disease - Diagnose By Specialist
 GASTROENTEROLOGY / HEPATOLOGY ORTHOPEDIC
Chronic Inflammatory Bowel Disease
Chronic Liver Disease Gangrene / Necrotizing Fasciitis Requiring Amputation
Fulminant Viral Hepatitis Knee Injury Requiring Surgery/Implant/Graft
Pulmonary Hypertension Osteoarthritis Requiring Surgery/Implant
Prolapse Intervertebral Disc With Significant Neurological Deficit
GENITOURINARY SYSTEM Requiring Surgery
Congenital Urinary Abnormalities Requiring Urgent And Major Shoulder Injury With Instability/Function Compromised Requiring
Surgical Intervention Surgery/Implant/Graft
Chronic Kidney Disease/Failure Spinal Stenosis With Significant Neurological Symptoms/Deficit
Medullary Cystic Disease Requiring Surgery
Renal Calculi Requiring Surgical Intervention Unstable Spine Fractures / Trauma Requiring Surgery And Implant/
Rehab Equipment

HEMATOLOGY RESPIRATORY SYSTEM

Aplastic Anaemia Bronchiectasis
Haemophilia (Moderate To Severe - Factor Activity <5%) Chronic Lung Disease
Hematological Malignancies – Leukemia, Multiple Myeloma Lung Fibrosis
(Acute Or Chronic Leukemia Diagnosed By Physician) Obstructive Sleep Apnoea
Hematopoietic Stem Cell Transplantation Secondary Pulmonary Hypertension
Idiopathic Thrombocytopenic Purpura (ITP) - Thrombocytopenia Severe Chronic Obstructive Pulmonary Disease (COPD) /
Refractory To Convention Steroid Treatment (1st Line Treatment) Emphysema
Lymphoma
Myeloproliferative Disorders Requiring Blood Transfusion And/Or
Chelating Agents
Thalassaemia Major Requiring Chelating Agent

ILLNESS OF CHILD UNDER 16 YEARS OLD RHEUMATOLOGY

Congenital Diseases Requiring Medical Or Surgical Intervention Ankylosing Spondyloarthritis Active Disease With Functional
Treated By Specialist Impairment And/Or Disability
Intellectual Impairment Due To Accident Or Sickness Chronic Tophaceous Gout With Functional Impairment And/Or
Leukaemia Disability.
Severe Asthma Psoriatic Arthritis Active Disease With Functional Impairment And
/Or Disability
Rheumatoid Arthritis / Arthritis Of Any Joint With Deformities
MENTAL ILLNESS Requiring Surgery/Orthosis
Bipolar Mood
Major Depression
Schizophrenia

MUSCULOSKELETAL SYSTEM OTHER DISEASES APPROVED BY EPF BOARD

Systemic Lupus Erythematosus (SLE) With Major Organ Involvement AIDS (Accompanied with AIDS defining disease) / HIV (Second Line
Systemic Sclerosis/Scleroderma With Functional Impairment Treatment)
And/Or Major Organ Involvement Deafness
Loss Of Independent Existence
Major Burns
Major Organ Transplant
Terminal Illness

9. BAHAGIAN INI HANYA PERLU DIISI BAGI Tahap penglihatan selepas pembetulan dengan cermin mata/kanta sentuh:
PENYAKIT YANG MELIBATKAN Vision level after correction with glasses/contact lens
OFTALMOLOGI. SILA TERUSKAN KE
BAHAGIAN 10 SEKIRANYA MELIBATKAN Mata kanan (Right eye): Mata kiri (Left eye):
LAIN-LAIN PENYAKIT.
Medan penglihatan:
Visual field
THIS SECTION IS ONLY REQUIRED TO BE
COMPLETED FOR AN OPHTHALMOLOGY Mata kanan (Right eye): Mata kiri (Left eye):
RELATED DISEASE. PLEASE PROCEED TO
SECTION 10 FOR OTHER ILLNESSES. Lain-lain hasil penyiasatan yang berkaitan:
Other related investigation results
(i) Optical coherent tomography (OCT):

(ii) Fundus angiography:

 Sila tandakan (x) pada petak yang berkaitan:
Please indicate (x) in the relevant box

Terhad di kedua-dua belah mata (penglihatan lebih teruk dari 6/18 tetapi sama
atau lebih baik daripada 3/60 ATAU medan penglihatan kurang dari 20 darjah
dari fixation).
Limited in both eyes (vision is worse than 6/18 but equal to or better than 3/60
OR visual field is less than 20 degrees from the point of fixation).
Buta kedua-dua belah mata (penglihatan kurang daripada 3/60 ATAU medan
penglihatan kurang daripada 10 darjah dari fixation).
Blindness of both eyes (vision is less than 3/60 OR visual field is less than 10
degrees from the point of fixation).

Buta di sebelah mata.

Blind in one eye

10. KETERANGAN LANJUT TENTANG PENYAKIT

DETAILED INFORMATION ABOUT THE
ILLNESS
11. SILA NYATAKAN IMPLIKASI PENYAKIT
TERSEBUT JIKA TIDAK DIRAWAT DENGAN
SEGERA
PLEASE STATE THE IMPLICATION IF THE
ILLNESS IS NOT TREATED IMMEDIATELY
12. PENYAKIT KRONIK / KRITIKAL
CHRONIC / CRITICAL ILLNESS YA / YES TIDAK / NO

13. LAIN-LAIN PENYAKIT YANG DIHIDAPI

OTHER ILLNESS

14. KAEDAH RAWATAN

TYPE OF TREATMENT

15. PERALATAN BANTUAN KESIHATAN Adakah kaedah rawatan memerlukan peralatan bantuan kesihatan ?
MEDICAL SUPPORT Is the type of treatment requires any medical support equipment and peripherals ?
EQUIPTMENT/PERIPHERALS REQUIRED
YA / YES TIDAK / NO

Jika ‘ Ya’, sila nyatakan / If ‘Yes’ please state :

16. PEMBEDAHAN (Jika ada)

SURGERY (If any)
17. KOS ANGGARAN RAWATAN / PERALATAN Kos Anggaran Rawatan : RM
BANTUAN KESIHATAN Estimated Treatment Cost
ESTIMATED TREATMENT / MEDICAL
SUPPORT EQUIPMENT AND PERIPHERALS Kos Anggaran Peralatan Bantuan Kesihatan : RM
COST Estimated Medical Support Equipment and Peripherals
*Hanya dilengkapkan bagi pesakit yang ingin Cost
mendapatkan rawatan di luar negara

SAYA SAHKAN MAKLUMAT YANG DIBERIKAN DI ATAS ADALAH BENAR

I CERTIFIED THAT THE INFORMATION GIVEN ABOVE IS TRUE

………………………………...........….......... TARIKH :
TANDATANGAN & NAMA DOKTOR, NO. MPM DATE
DAN COP RASMI HOSPITAL
SIGNATURE & DOCTOR’S NAME
AND HOSPITAL OFFICIAL STAMP