Work Pass Division

1 I Havelock Road MINISTRY OF

Sind2n^ra nqq7A4
MANPOWEH
Boon Lay X-ray Centre
221 BOON LAYPLACE#01-108 Tel: 6288521',

ID T3666780 NationalitY : lndian

l Form For Foreign Workers
Ret No : 065665
D.O.B. : 20-Mar1991 (30 Yrs) r registered doctor. Any amendments must be endorsed by the doctor who
Allergy :
: must be produced to the doctor for identification,

DATE' 09 AW 2A21 10:13:37 AM

rssport No._ Sex: "Male / Female Heisnt: [?Lt cm

Occupation: htlkrLirrt v&RV*P Date of Birth. Citizenship: weignt: L? l rg

Part ll Medical History (To be declared and signed by the foreign worker)

Yes No lf yes, give brief details Yes No lf yes, give brief details
1 Mental illness trd, 6 Tuberculosis n
w
2
3
Epilepsy nd.
nd
7
8
Heart Disease !
tr il,
4
5
Chronic Asthma
Diabetes Mellitus E'd I
Malaria
Operations n V
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 to the Ministry of Manpower, my employer, and also to the employment agent who assisted in my work permit application.

9. t g APR 2t?1
Signature of Foreign Worker Date

Part lll Please tick if any of the Examinations / Tests is Abn ormal and g ive brief deta ils separately.

Clinical Examinations Abnormal Other Tests Abnormal

1 CardiovascularSystem Chest X-ray to be taken in Singapore (-For any
- n
a Blood Pressure T abnormalities and other findings including no active
L r-l 4/r,,o*r^,,
Systolic: lung lesion, please state here and attach the chest
\ '''l
Diastolic:
.b Heart Disease {
radiological report to this form.)
n
c ECG (compulsory for male Thai workers & others n
above age 50, and in younger applicants where it is
indicated, e.g. persons with cardic murmurs or
symploms suggestive of Myocardial ischaemia) 2 Urine tr
d Severe varicose veins - a Albumin 1 p,-.a6.trlt tr
2 Anaemia (if clinically anaemic, do HB. go) D Sugar -,1 J tr
3 Respiratory Svstem c Preqnancy t-t
4 Abdomen 3 VDRL D
a Hernia f 4 Hearing - unable to hear ordinary conversation at 2m x
b Enlarged Liver tr 5 Vision (should be alleast6112 in both eyes with Ll
c Enlarged Spleen tr or without glasses.)
d Genito-Urinary System f a Vision Acuity n
5 Skin-Chronic Disease (e.9. leprosy, widespread n i) Right eye n
eczema, Dsoriasis, etc) ii) Left eye u
6 Locomotor/Neurological b Colour Vision (for electricians & drivers only) tr
a Signiflcant limb amputation or deformity n c Anv orqanic eve disease, e.q. Trachoma ft
b Limb movement and co-ordination n 6 Blood {ilm for Malaria tr
c Signiflcant spinal deformity n 7 HtV (ArDS) I
d Other significant abnormalities (in relation to the n Note:
Work required to be performed) HIV (AIDS) Test and 6lood film for Malaria must be
7 Endocrine disorders, e.g. thyrotoxicosis done at laboratories approved by the Ministry
8 Mental state of Health.

Part lV Certification from the Doctor

(in BLOCK Letter) Signature of Doctor:

Clinic Address: Date:
DLEDD IVItrUIUAL CENTRE PTE LTD
Telephone Number:

*Detetewhereinappticabte
-^Iul;19d.!,.1Sapcre640221
Ier: h256 4119 Fax..6266 7B5S
Doctors to Note:
Please send the medical form back to the

EEEfoi-n The information is updated on27 Mar 2O18