MEDICAL EXAMINATION FORM

Note: This form is to be completed by a qualified doctor and returned to the examinee.
A

PERSONAL PARTICULARS
Name (as in IC)

Gender

M/F

Personal/Family Medical History

B

Age:

I/C No:

PHYSICAL EXAMINATION
Height
Eye

Weight
Visual Acuity

R=

+ / - Glasses

L=

Normal

Abnormal

Remarks

Colour Vision
Fundus
Ear/Nose
Mouth/Throat
Chest/Lungs
Cardiovascular
Pulse

/min

Blood Pressure

mmHg

Abdomen
Musculoskeletal / Spine
Nervous System
Lymph Nodes
Endocrine System
Skin
C

INVESTIGATION
Urinalysis
Audiometry

Note: Pregnant women are

exempted from Chest X-Ray.
Please tick below if
examinee is pregnant.

Chest X-Ray
Lung Function
Other Test:
Urine FEME
Urine for Morphine and Cannabinoids

Examinee is pregnant.

Remarks/Recommendation:

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MEDICAL EXAMINATION FORM

Note: This form is to be completed by a qualified doctor and returned to the examinee.
PERSONAL PARTICULARS

Name (as in IC)

Gender

M/F

Age:

I/C No:

CERTIFICATION
I certify that I have examined the above-named person and my findings are as above.
I also certify that he/she is FIT / UNFIT (circle whichever relavant) for employment.
Reason (if UNFIT):

Name of Examining Doctor:

Date:

Signature:

Clinic's Stamp & Address:

Contact Number:

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