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
AGE / GENDER
8.
PENYAKIT YANG DIHIDAPI / ILLNESS
Sila tandakan (x) pada ruangan yang disediakan / Please indicate (x) below
KATEGORI/JENIS PENYAKIT KRITIKAL
CANCER
NERVOUS SYSTEM
Cancer
Alzheimer’s Disease
Appalic Syndrome
Benign Tumor Of Brain
Cerebral Palsy
Coma
Encephalitis
Loss Of Speech
Major Head Trauma
Meningitis
Motor Neurone Disease
Multiple Sclerosis
Muscular Dystrophy
Paralysis
Parkinson’s Disease
Poliomyelitis
Stroke
Total Permanent Disability
CARDIOVASCULAR SYSTEM
Arrhythmia Requiring Device Insertion (Pacemaker/Defibrillator)
Cardiomyopathy/Heart Failure
Congenital Heart Disease
Constrictive Pericarditis
Coronary Artery Disease/Ischaemic Heart Disease
Heart Attack / Myocardial Infarction
Heart Block Requiring Surgical Intervention/Pacemaker/Battery
Implant
Heart Valve Replacement / Valvular Heart Disease Requiring
Replacement
Peripheral Vascular Disease
Surgery to Aorta / Diseases of the Aorta Requiring Surgery
ENDOCRINE/MEDICAL
OPHTHALMOLOGY
(Sila penuhkan juga Ruangan 9/Please also complete paragraph 9)
Epilepsy & Movement Disorders Requiring Deep Brain Stimulation Or
Surgery
Guillain Barre Syndrome Requiring Immunoglobulin Treatment
Morbid Obesity Or Obesity With Multiple Medical Complications And
Life Threatening Requiring Bariatric Surgery
Pituitary Tumors
Sepsis With One Or More Major Organ Failure
Type 1 Diabetes With Criteria For Insulin Pump Therapy
Advanced Diabetic Eye Disease - Diagnose By Specialist
Age Related Macular Degeneration (Armd)/Polypoidal Choroidal
Vasculopathy (PCV)
Blindness
Cataract Requiring Surgery (Intraocular Lens IOL)
Corneal Disorders Requiring Corneal Surgery (Corneal Transplant)
Diagnose By Specialist
Enopthalmic Socket - Diagnose By Specialist
Glaucoma Requiring Surgery With Glaucoma Implant
Retinal Vascular Disease - Diagnose By Specialist
LELAKI /
MALE
PEREMPUAN /
FEMALE
LPP-1
Tarikh cetakan : April2020
1
GASTROENTEROLOGY / HEPATOLOGY
Chronic Inflammatory Bowel Disease
Chronic Liver Disease
Fulminant Viral Hepatitis
Pulmonary Hypertension
Gangrene / Necrotizing Fasciitis Requiring Amputation
Knee Injury Requiring Surgery/Implant/Graft
Osteoarthritis Requiring Surgery/Implant
Prolapse Intervertebral Disc With Significant Neurological Deficit
Requiring Surgery
Shoulder Injury With Instability/Function Compromised Requiring
Surgery/Implant/Graft
Spinal Stenosis With Significant Neurological Symptoms/Deficit
Requiring Surgery
Unstable Spine Fractures / Trauma Requiring Surgery And Implant/
Rehab Equipment
GENITOURINARY SYSTEM
Congenital Urinary Abnormalities Requiring Urgent And Major
Surgical Intervention
Chronic Kidney Disease/Failure
Medullary Cystic Disease
Renal Calculi Requiring Surgical Intervention
HEMATOLOGY
Aplastic Anaemia
Haemophilia (Moderate To Severe - Factor Activity <5%)
Hematological Malignancies Leukemia, Multiple Myeloma
(Acute Or Chronic Leukemia Diagnosed By Physician)
Hematopoietic Stem Cell Transplantation
Idiopathic Thrombocytopenic Purpura (ITP) - Thrombocytopenia
Refractory To Convention Steroid Treatment (1st Line Treatment)
Lymphoma
Myeloproliferative Disorders Requiring Blood Transfusion And/Or
Chelating Agents
Thalassaemia Major Requiring Chelating Agent
Bronchiectasis
Chronic Lung Disease
Lung Fibrosis
Obstructive Sleep Apnoea
Secondary Pulmonary Hypertension
Severe Chronic Obstructive Pulmonary Disease (COPD) /
Emphysema
ILLNESS OF CHILD UNDER 16 YEARS OLD
RHEUMATOLOGY
Congenital Diseases Requiring Medical Or Surgical Intervention
Treated By Specialist
Intellectual Impairment Due To Accident Or Sickness
Leukaemia
Severe Asthma
Ankylosing Spondyloarthritis Active Disease With Functional
Impairment And/Or Disability
Chronic Tophaceous Gout With Functional Impairment And/Or
Disability.
Psoriatic Arthritis Active Disease With Functional Impairment And
/Or Disability
Rheumatoid Arthritis / Arthritis Of Any Joint With Deformities
Requiring Surgery/Orthosis
MENTAL ILLNESS
Bipolar Mood
Major Depression
Schizophrenia
MUSCULOSKELETAL SYSTEM
Systemic Lupus Erythematosus (SLE) With Major Organ Involvement
Systemic Sclerosis/Scleroderma With Functional Impairment
And/Or Major Organ Involvement
AIDS (Accompanied with AIDS defining disease) / HIV (Second Line
Treatment)
Deafness
Loss Of Independent Existence
Major Burns
Major Organ Transplant
Terminal Illness
9.
BAHAGIAN INI HANYA PERLU DIISI BAGI
PENYAKIT YANG MELIBATKAN
OFTALMOLOGI. SILA TERUSKAN KE
BAHAGIAN 10 SEKIRANYA MELIBATKAN
LAIN-LAIN PENYAKIT.
THIS SECTION IS ONLY REQUIRED TO BE
COMPLETED FOR AN OPHTHALMOLOGY
RELATED DISEASE. PLEASE PROCEED TO
SECTION 10 FOR OTHER ILLNESSES.
Tahap penglihatan selepas pembetulan dengan cermin mata/kanta sentuh:
Vision level after correction with glasses/contact lens
Mata kanan (Right eye): Mata kiri (Left eye):
Medan penglihatan:
Visual field
Mata kanan (Right eye): Mata kiri (Left eye):
Lain-lain hasil penyiasatan yang berkaitan:
Other related investigation results
(i) Optical coherent tomography (OCT):
(ii) Fundus angiography:
Tarikh cetakan : April2020
2
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
MEDICAL SUPPORT
EQUIPTMENT/PERIPHERALS REQUIRED
Adakah kaedah rawatan memerlukan peralatan bantuan kesihatan ?
Is the type of treatment requires any medical support equipment and peripherals ?
Jika ‘ Ya’, sila nyatakan / If ‘Yes’ please state :
16.
PEMBEDAHAN (Jika ada)
SURGERY (If any)
17.
KOS ANGGARAN RAWATAN / PERALATAN
BANTUAN KESIHATAN
ESTIMATED TREATMENT / MEDICAL
SUPPORT EQUIPMENT AND PERIPHERALS
COST
*Hanya dilengkapkan bagi pesakit yang ingin
mendapatkan rawatan di luar negara
Kos Anggaran Rawatan : RM
Estimated Treatment Cost
Kos Anggaran Peralatan Bantuan Kesihatan : RM
Estimated Medical Support Equipment and Peripherals
Cost
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
TIDAK / NO
YA / YES
Tarikh cetakan : April 2020
3
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