Full Medical Examination Form For Foreign Workers All parts in this form are to be completed by a Singapore registered doctor. Any amendments must be endorsed by the doctor who completes this form. The foreign worker’s Travel Document must be must be produced to the doctor for identification. Part I
I declare declare that all the information given a above bove is true and correct. I hereby hereby give my consent consent for a copy of t his medical medical form aft er it is completed by the doctor to be released to the Ministry of Manpower, my employer, and also to the employment agent who assisted in my work permit application.
Signature Signature of Foreign Worker Part III
Date
Please tick if any of the Examinations / Tests is Abnormal and give brief details separately.
Clinical Examinations 1 Cardiovascula Cardiovascularr System a Blood Pressure Pressure Systolic: Diastolic: Diastolic: b Heart Disease Disease c ECG (compulsory for male Thai w orkers & others above age age 50, and in younger applicants applicants w here it is indicated, e.g. persons with cardic murmurs or symptoms suggestiv suggestiv e of Myocardial ischaemia) ischaemia) d Severe varicose veins 2 Anaemia (if clinically anaemic, do HB: ____ ______ ____ __ g% ) 3 Respiratory System 4 Abdomen a Hernia b Enlarged nlarged Liver c Enlarged Spleen d Genito-Urinary Genito-Urinary System 5 Skin-Chronic Disease (e.g. leprosy, w idespread eczema, eczema, psoriasis, psoriasis, etc) 6 Locomotor/Neurologica Locomotor/Neurologicall a Significant limb amputation or deformit y b Limb movement and co-ordination c Significant spinal deformit y d Other significant abnormalities abnormalities (in relation to the Work required required to be performed) 7 Endocrine disorders, disorders, e.g. thy rotoxicosis 8 Mental state
Abnormal
Other Tests 1 Chest Chest X-ray – t o be taken in Singapore Singapore (* For any abnormalit ies and ot her fi ndings including no act ive lung lesion, please please stat e here and att ach the chest radiological radiological report to this form. )
2 Urine a Albu min b Sugar c Pregnancy Pregnancy 3 VDRL VDRL 4 Hearing – unable to hear ordinary conversation at 2m 5 Vision (should be at least least 6/1 2 in both eyes w ith or w it hout glasses.) a Vision Acuit y i) Right eye ii) Left eye b Colour Colour Vision (for electricians & drivers only) c Any organic eye disease, disease, e.g. Trachoma 6 Blood film for Malaria 7 HIV (AIDS) Note: HIV (AIDS) Test Test and blood film f or Malaria must be done at laboratories laboratories approved by the Ministry of Health. Health.
Part IV Certification from the Doctor I certify that I have examined the above-named above-named foreign w orker for t he clinical clinical examinations examinations / t ests in Part Part III and found that this person is * Fit / Unfit Unfit for employment in the above-stated occupation. Name of Doctor: (in BLOC BLOCK K Letter)
Signature Signature of Doctor:
Clinic Address:
Date: Telephone Number:
Delete w here inapplicable inapplicable * Delete
Doctors to Note: Please give a copy of the completed medical form to the employer / employment agent if he / she asks for it. WPCM 015
