Full Name
*
UKMPER
*
Address
Number and Street Address
Address Line 2
City
State
Zip Code
Postcode
Please Select
Johor
Kedah
Kelantan
Kuala Lumpur
Labuan
Melaka
Negeri Sembilan
Pahang
Perak
Perlis
Pulau Pinang
Putrajaya
Sabah
Sarawak
Selangor
Terengganu
State
Gender
*
Male
Female
Weight (Kg)
*
Height (cm)
*
Age (in years)
*
Phone number
*
Email
*
example@example.com
Faculty/Institute (PTJ):
*
Please Select
Faculty of Social Science and Humanities
Faculty of Science and Technology
Faculty of Islamic Studies
Faculty of Medicine
Faculty of Health Sciences
Faculty of Dentistry
Faculty of Economics and Management
Faculty of Education
Faculty of Engineering and Built Environment
Faculty of Information Science and Technology
Faculty of Pharmacy
Faculty of Law
Graduate School of Business
Fuel Cell Institute (SELFUEL)
Institute for Environment & Development (LESTARI)
Institute for Malaysian & International Studies (IKMAS)
Institute of Ethnic Studies (KITA)
Institute of Microengineering & Nanoelectronics (IMEN)
Institute of Climate Change (IPI)
Institute of Systems Biology (INBIOSIS)
Institute of the Malay World & Civilization (ATMA)
Institute of Visual Informatics (IVI)
Institute of Islam Hadhari (HADHARI)
UKM Medical Molecular Biology Institute (UMBI)
Solar Energy Research Institute (SERI)
Institute of Ear, Hearing & Speech (I-HEARS)
Institute of 4IR
Others (Please specify)
Faculty/Institute (Others):
*
Health issues
*
Diabetes
High blood pressure
High cholesterol
Heart diseases
Other
None
Current Medication (Diabetes)
Gliclazide (Diamicron)
Glimiperide (Amaryl)
Glibenclamide (Daonil)
Repaglinide (Novonorm)
Nateglinide (Starlix)
Glucophage (Metformin)
Acarbose (Glucobay)
Rosigitazone (Avandia)
Pioglitazone (Actos)
Saxagliptin (Kombiglyze)
Linagliptin (Trajenta)
Vildagliptin (Galvus)
Sitagliptin (Januvia)
Empaglifozin (Jardiance)
Dapaglifozin (Forxiga)
Luseoglifozin (Lusefi)
Canaglifozin (Invokana)
Insulatard
Actrapid
Mixtard
Lantus (Glargine)
Levemir (Detemir)
Basalog insulin
Novorapid (Aspart)
Humalog (Lispro)
Novomix 30
Humalog mix 50
Humalog mix 20
Ryzodeg
Liraglutide (Victoza)
Dulaglutide (Trulicity)
Semaglutide (Ozempic)
Current Medication (High blood pressure)
Amlodipine (Norvasc)
Felodipine (Plendil)
Diltiazem
Nifedipine (Adalat)
Verapamil (Verelan, Isoptin)
Prazosin (Minipress)
Doxazosin (Cardura)
Atenolol (Tenormin)
Metoprolol (Betaloc)
Proponolol (Inderal)
Bisoprolol
Labetolol
Enalapril
Captopril (Capoten)
Lisinopril
Perindopril
Ramipril
Candesartan (Atacand)
Irbesartan
Termisartan (Micardis)
Valsartan (Diovan)
Losartan (Cozaar)
Hydrochlorothizide
Indapamide (Natrilix)
Chlorothizide
Spironolactone (Aldactone)
Amiloride
Bumetanide(Burinex)
Frusemide (Lasix)
Moduretic
Methyldopa (Aldomet)
Clonidine (Catapres)
Hydralazine
Eplerenone (sample)
Current Medication (High cholesterol)
Atorvastatin (Lipitor)
Rosuvastatin (Crestor)
Atozet
Carduet
Simvastatin (Zocor)
Pravastatin (Pravachol)
Ezetemibe (Ezetrol)
Vytorin
Fenofibrate (Lipanthyl)
Current Medication (Heart diseases)
Current Medication (Others)
Allergies (None if no allergies)
*
Smoking
*
Yes
No
Alcohol consumption
*
Yes
No
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