Full Medical Examination Form
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1Work Pass Division
18 Havelock Road
Singapore 059764
w w w .mom.gov.sg
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 produced to the doctor for identification.
Part I
Personal Particulars of Foreign Worker
Name: ________________________________________
Passport No._______________
Sex: * Male / Female
Height: __________ cm
Occupation: __________________________________
Citizenship: ____________
Weight: __________ kg
Date of Birth: _______________
Part II
Medical History (To be declared and signed by the foreign worker)
Yes
No
If yes, give brief details
Yes
No
If yes, give brief details
1
Mental illness
6
Tuberculosis
2
Epilepsy
7
Heart Disease
3
Chronic Asthma
8
Malaria
4
Diabetes Mellitus
9
Operations
5
Hypertension
I declare that all the information given above is true and correct . I hereby give my consent for a copy of this medical form after it is
completed by the doctor to be released to the Ministry of Manpow er, my employer, and also to the employment agent w ho assisted in my
w ork permit application.
Signature of Foreign Worker
Date
Part III Please tick if any of the Examinations / Tests is Abnormal and give brief details separately.
Clinical Examinations
Abnormal
Other Tests
Abnormal
1 Chest X-ray – to be taken in Singapore (* For any
1 Cardiovascular System
a Blood Pressure
abnormalities and other findings including no active
Systolic:
lung lesion, please state here and attach the chest
Diastolic:
radiological report to this form.)
b Heart Disease
c
ECG (compulsory for male Thai w orkers & others
above age 50, and in younger applicants w here it is
indicated, e.g. persons w ith cardic murmurs or
symptoms suggestive of Myocardial ischaemia)
2 Urine
d Severe varicose veins
a Albumin
2 Anaemia (if clinically anaemic, do HB: ________ g% )
b Sugar
3 Respiratory System
c
Pregnancy
4 Abdomen
3 VDRL
Hearing – unable to hear ordinary conversation at 2m
a Hernia
4
b Enlarged Liver
5 Vision (should be at least 6/12 in both eyes w ith
c
Enlarged Spleen
or w ithout glasses.)
d Genito-Urinary System
a Vision Acuity
5 Skin-Chronic Disease (e.g. leprosy, w idespread
i) Right eye
eczema, psoriasis, etc)
ii) Left eye
6 Locomotor/Neurological
b Colour Vision (for electricians & drivers only)
a Significant limb amputation or deformity
c
Any organic eye disease, e.g. Trachoma
b Limb movement and co-ordination
6 Blood film for Malaria
c
Significant spinal deformity
7 HIV (AIDS)
d Other significant abnormalities (in relation to the
Note:
Work required to be performed)
HIV (AIDS) Test and blood film f or Malaria must be
7 Endocrine disorders, e.g. thyrotoxicosis
done at laboratories approved by the Ministry
8 Mental state
of Health.
Part IV Certification from the Doctor
I certify that I have examined the above-named foreign w orker for the clinical examinations / tests in Part III and found that this
person is * Fit / Unfit for employment in the above-stated occupation.
Name of Doctor:
(in BLOCK Letter)
Signature of Doctor:
Clinic Address:
Date:
Telephone Number:
* Delete w here inapplicable
Doctors to Note:
Please give a copy of the completed medical form to the employer / employment agent if he / she asks for it.
The information is updated on 16 Dec 2015
WPCM
015
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