PRE-ADMISSION MEDICAL EXAMINATION FORM (HIGHER NITEC IN EARLY CHILDHOOD EDUCATION) (SERVICE CODE FOR SATA: ITE-HS/EC/SS)

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1 PRE-ADMISSION MEDICAL EXAMINATION FORM (HIGHER NITEC IN EARLY CHILDHOOD EDUCATION) (SERVICE CODE FOR SATA: ITE-HS/EC/SS) PART A : TO BE COMPLETED BY STUDENT Full name : NRIC. : Contact numbers : Address : Please indicate whether you have ever had or do have any of these illnesses and conditions. All items MUST be answered. Please circle accordingly. Frequent headaches / dizziness / Jaundice (yellow eyes / skin) fainting spells Epilepsy or fits Bone problems (e.g., fracture, deformity) Blindness in one eye (left / right) Frequent backache Colour blindness Chronic disease / condition of skin (e.g., rashes, eczema) Any chronic eye disease Chronic disease / condition of nail Hearing difficulties or deafness Mental illness or other problems (one / both ears) (e.g. frequent depression, anxiety) Wearing of hearing aid (one / both Any psychiatric treatment. If yes, ears) specify : Ear ache or ear discharge Tremours of fingers or sweaty palms Constant sneezing / running nose Stammering or speech problems Asthma Any surgical operation. If yes, specify : Tuberculosis (TB) Currently on medication. If yes, specify : Hepatitis A Allergy history. If yes, specify: Hepatitis B Smoking. If yes, no. of sticks per day : Kidney / bladder disease Tattoo on body. If yes, location(s) : Any other condition not listed above, please specify : While not comprehensive, the following medical conditions will lead to non-acceptance into the Early Childhood Education course. Active tuberculosis Uncontrolled epilepsy Psychiatric condition Legal blindness Uncontrolled asthma Profound deafness Uncontrolled diabetes Uncontrolled hypertension Mobility restricted HBsAg positive / Hepatitis B Carrier Acquired immune deficiency syndrome (AIDS) Physical dependence upon mobility equipment 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(s). Should I be admitted to ITE on the basis of the information given in this form which may later turn out to be false or inaccurate, I understand that I will render myself liable to appropriate disciplinary action, including dismissal from the course. Date Signature of student Updated Sep 17

2 PART B : TO BE COMPLETED BY EXAMINING DOCTOR Full name of student : NRIC. : Please refer to bottom of page 1 for the list of medical conditions that will lead to nonacceptance into the Early Childhood Education course. History of epilepsy Colour blindness History of mental illness * / Remarks : * / Remarks : * / Remarks : Height (m) : Weight (kg) : BMI score : (normal BMI: ) Acuity of vision R L * Glasses / glasses Urine analysis: Glucose Protein Blood Blood analysis: Hb% HB Profile : HBs Ag HB Antibody Lungs (chest x-ray to be attached) * rmal / Abnormal Remarks : Pulse : Blood pressure : Ears : se : Throat : Heart : Skin : Abdomen & pelvis : Hernia or enlarged rings : Back & spine : Haemorrhoids : Injury, operations or illness : Lungs : General physique : Mental disposition: I have hereby completed a medical examination of this student. I find him / her to be * free / suffering from organic and infectious disease and is physically and mentally *fit / unfit to pursue the Higher Nitec in Early Childhood Education course which involves direct contact with young children. Remarks, if any : *If doctor requires further clarification on the requirements of the Higher Nitec in Early Childhood Education course, please contact Ms Dorcas Tang, CM/AEV/CC, at or Ms Jerine Chng, SH/ECH/CC, at Name of doctor : Signature of doctor : Name and address of practice : Date of medical examination : * delete where appropriate Updated Sep 17

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5 HEALTHWAY MEDICAL GROUP - BRANCHES & CONSULTATION HOURS APPOINTED GENERAL PRACTITIONER CLINICS NO LOCATION BRANCH/CLINIC DOCTOR MON FRI SAT, SUN & PUBLIC HOLIDAYS 01 Ang Mo Kio Central Healthway AMK Clinic Blk 721 Ang Mo Kio Avenue 8 # Singapore (560721) Tel: Fax: Dr Bertram Chia 8:00am-1:00pm 6:00pm-9:00pm Sat 8:00am 1:00pm Sun & PH 9.00am-12:00pm 02 Toa Payoh Central Healthway Toa Payoh Clinic Blk 177 Toa Payoh Central # Singapore (310177) Tel: Fax: Dr Joyce Seng * 8:00am 4:00pm Sat, Sun & PH 8:30am 1:00pm 03 Bedok rth Bedok Family Clinic & Surgery Blk 218 Bedok rth St 1 #01-17 (Near Bedok Mrt Station) Singapore (460218) Tel: Fax: Westgate Healthway Medical Clinic 3 Gateway Drive #04-32, Westgate Singapore Tel: Fax : Dr Queenie Lim* Dr Tok Ern Cai Dr Ho Lik Man 8:00am 1:00pm 2:00pm 5:00pm 6:00pm 11:00pm Mon Fri 9:00am-1:00pm 6.30pm-9:00pm Sat, Sun & PH 8:00am-1:00pm 6:00pm-11:00pm Sat 9:00am-1:00pm Sun & PH 10:00am-2:00pm Lady Doctor* Higher consultation rates apply for 9:30pm - 12 midnight** For Students enrolled in Beauty & wellness, Beauty & Spa Management, Community Care & Social Services, Early Childhood Education, Hair Fashion & Design, Nursing and Paramedic & Emergency Care courses, please proceed for medical examination before 2.30pm on weekdays and before 10am on Saturdays. GP services are also available to ITE Students at preferential rates. For more details of the clinics and operational hours, please visit Healthway Medical Group Pte Ltd 6 Shenton Way, #10-09 OUE Downtown 2, Singapore Tel: Fax: Company Registration : H