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| Question | Answer |
|---|---|
| Form Name | Medical Form Singapore |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names |
MEDICAL REPORT (2014)
Medical Report Form
Admission Number
(This medical report will not be returned to the student)
This form may take you 3 minutes to ill. The data provided will be kept strictly conidential and used for the purpose of assessing itness for admission to a course.
Students with the following medical conditions should not pursue the respective courses stipulated.
•If you are suffering from colour vision deiciency, you should not pursue the following courses:
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Applied Chemistry with |
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Chemical Engineering |
- Food Science & Technology |
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Pharmaceutical Science |
- Electrical & Electronic Engineering |
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Marine Engineering |
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Biomedical Science |
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Engineering Systems |
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Nautical Studies @ |
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Biotechnology |
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@Student must pass the Maritime and Port Authority of Singapore Sight Test.
•If you are suffering from either colour vision deiciency or hearing loss (partial or complete), you should not pursue the following courses:
- Aeronautical Engineering |
- Aerospace Electronics |
- Energy Systems and Management |
•If you are suffering from or have a history of epilepsy, you should not pursue an Engineering course.
•For the Computer Engineering course, if you are suffering from impairments, you must be prepared to appear for interviews and to undergo any manual dexterity or aptitude tests.
•For the Visual Effects and Motion Graphics course, if you are suffering from colour vision deiciency, you will be required to attend an interview to determine your suitability for admission to the course.
•Students with Autism / Asperger Syndrome may be referred to a psychiatrist to help them to prepare for a new learning environment.
PART 1 – TO BE COMPLETED BY STUDENT
APersonal Particulars
Name: |
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NRIC / Foreign Identiication: |
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Date of Birth: |
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Handphone: |
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Gender: Male / Female |
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B Medical Information |
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1. Family Doctor / Clinic: |
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2.Do you have or have you ever had any of the following conditions? Please indicate by checking ( ) the appropriate column. If your answer is 'Yes', give details (#) below and attach medical report (if necessary):
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Yes |
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Active Tuberculosis |
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Autism / Asperger Syndrome |
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Hearing Loss |
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Allergies |
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Colour Vision Deiciency |
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HIV Positive / AIDS |
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Asthma |
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Diabetes |
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Hypertension |
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Attention Deicit Hyperactivity |
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Dyslexia |
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Psychiatric Condition |
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Disorder (ADHD / ADD) |
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Epilepsy |
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Vision Loss (excluding myopia) |
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Other Medical Conditions: |
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Other Physical Disability: |
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(#) Details:
3.Please provide your Family, Social and Drug history by checking below. If your answer is 'Yes', give details.
Yes |
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Details |
i)Family History
Diabetes Hypertension Heart Disease Psychiatric Condition Stroke Tuberculosis
ii)Social History
Smoking |
Number of sticks per day : |
(Smoking is a disciplinary offence on campus.) |
Alcohol |
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iii)Drug History
Drugs taken presently
Allergies
I hereby declare that all the information provided is true and accurate to the best of my knowledge and I have not deliberately omitted any relevant fact. I agree to a medical practitioner completing the form overleaf for submission to SP on my behalf.
Student's Signature: |
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Date: |
Name : |
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Admission No : |
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Course : |
PART 2 – TO BE COMPLETED BY A MEDICAL PRACTITIONER REGISTERED IN SINGAPORE ONLY
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Height (m) : |
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BMI = |
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Urine Analysis: |
Glucose |
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Weight (kg) : |
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(Height in m)2 |
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Protein |
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If BMI > = 23 (moderate - |
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BMI : |
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high risk) |
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Blood |
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Acuity of Vision |
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Colour Vision (tick one only) |
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Ishihara Test |
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Without glasses |
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Normal |
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With glasses |
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Partial: Red / Green deiciency |
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History of Epilepsy: |
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Yes |
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No |
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If yes, |
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Complete: Red / Green deiciency |
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Recovered |
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Still on Medication |
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Chest |
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PHYSICAL EXAMINATION |
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Eyes : |
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Blood Pressure : |
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Ears : |
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Pulse : |
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Nose : |
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Heart : |
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Teeth : |
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Abdomen & Pelvis : |
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Gums : |
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Hernia (Enlarged Rings) : |
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Tonsils : |
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Skin : |
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Back / Spine : |
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Mental Disposition : |
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Injury, Operation, Illness: |
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Referrals (All fees are to be borne by the student.)
-Those with or suspected to have psychiatric condition must be referred to a psychiatrist for further assessment.
-Those with epilepsy must be referred to a Designated Workplace Doctor who will assess their itness for courses.
Blood Test (May be required at the discretion of the Medical Practitioner. All fees are to be borne by the student.) Test Result :
Certiication of Fitness
1.I have today completed a medical examination of the person named overleaf and ind this student for admission to be free / not free* from organic and infectious diseases.
2.The student is physically and mentally
•Fit / Unit* to pursue the course indicated.
•Fit / Unit* to pursue Any Other Course / Other Courses*
Remarks (if any) :
* Please delete accordingly. The student is deemed unit unless certiied it.
To be completed by the Medical Practitioner if the student is enrolling for the Diploma in Marine Engineering / Nautical Studies Course only
•Diploma in Marine Engineering Course
The student is it / unit* to be employed on board ship as Cadet Engineer / Engineer Oficer.
•Diploma in Nautical Studies Course
The student is it / unit* to be employed on board ship as a Cadet Deck Oficer.
Name of Registered Medical Practitioner:
Qualiications: |
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(Signature of Doctor) |
(OFFICIAL STAMP) |
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Name and Address of Practice: |
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Date: |
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Medical
•Successful Applicants of all
•Bring along your SP Medical Report Form to the clinic. You may go to your own family doctor, private or company clinics for the medical
1)or mail in to Admissions Ofice, Singapore Polytechnic, 500 Dover Road, Singapore 139651 as soon as you have received it from your doctor.
•Alternatively, you may go to any one of the clinics listed. Those who go for their medical
•All
•Students will bear all medical charges including any referrals to Designated Workplace Doctors or other Specialists.
•If the doctor has recommended you to undergo a blood test, the cost of this blood test is additional. Initial blood test is estimated at S$20.00.
Please inform the Admissions Ofice immediately should you have a medical condition that prohibits you from pursuing the offered course (e.g. colour vision deiciency). SP will need to arrange for a course transfer.
Call
Clinics |
Opening Hours |
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SATA CommHealth
You may wish to avoid the peak periods: weekday mornings and Saturdays as waiting times can be stretched. Rate:
• Singaporean / Permanent Resident: S$30.00 (inclusive of 7% GST)
• International Student: S$49.00 (inclusive of 7% GST)
SATA Uttamram Medical Centre |
Monday To Friday |
8.30 am to 5.00 pm |
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351 Chai Chee Street |
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Singapore 468982 |
Saturday |
Tel: |
8.30 am to 1.00 pm |
MRT Station: Bedok |
Weekend Surcharge: S$8.00 |
Bus Service: |
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222 (from Bedok MRT Station, in front of Blk 27, New Upper Changi Road) |
Closed on Sundays & Public Holidays |
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SATA Jurong Medical Centre |
Monday To Friday |
8.30 am to 5.00 pm |
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Blk 135 Jurong Gateway Road |
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Saturday |
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Singapore 600135 |
8.30 am to 1.00 pm |
Tel: |
Weekend Surcharge: S$8.00 |
MRT Station: Jurong East |
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Bus Service: |
Closed on Sundays & Public Holidays |
51, 66, 78, 79, 97, 98, 105, 197, 331 |
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SATA Woodlands Medical Centre |
Monday To Friday |
8.30 am to 5.00 pm |
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900 South Woodlands Drive |
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Saturday |
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Singapore 730900 |
8.30 am to 1.00 pm |
Tel: |
Weekend Surcharge: S$8.00 |
MRT Station: Woodlands |
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Bus Interchange: |
Closed on Sundays & Public Holidays |
161, 168, 169, 178, 187, 856, 858, 900, 900A, 901, 902, 903, 911, 912, 913, 925, |
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926, 950, 960, 961, 962, 963, 963E, 964, 965, 966, 967, 968, 969, 970, 971 |
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SATA Ang Mo Kio Medical Centre |
Monday To Friday |
8.30 am to 5.00 pm |
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Blk 715 Ang Mo Kio Avenue 6 |
Evening Clinic |
Singapore 560715 |
6.00 pm to 9.00 pm |
Tel: |
Surcharge: S$5.00 |
MRT Station: Ang Mo Kio |
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Bus Interchange: |
Saturday |
13, 86, 138, 162, 851, 852, 853 |
8.30 am to 1.00 pm |
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Weekend Surcharge: S$8.00 |
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Closed on Sundays & Public Holidays |
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• Singaporean / Permanent Resident: S$28.00 (inclusive of 7% GST) |
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• International Student: S$47.50 (inclusive of 7% GST) |
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Ang Mo Kio – Thye Hua Kwan Hospital |
Monday To Thursday |
17 Ang Mo Kio Avenue 9 |
8.45 am to 3.30 pm |
Singapore 569766 |
Lunch (Closed):12.00 noon to 2.00 pm |
Tel: |
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MRT Station: Yio Chu Kang |
Friday and Saturday |
Bus Service: |
8.45 am to 12.00 noon |
76, 265, 268 |
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Closed on Sundays & Public Holidays |
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Last appointment for AM session is at 11am |
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Last appointment for PM session is at 3 pm |
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