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Health Declaration Form

This document is a health declaration form that collects an individual's personal details and medical history. It asks for information such as name, age, address, medical conditions, operations, accidents, illnesses, and pregnancy status. It also includes a COVID-19 health record section asking about vaccination status, test results, and reasons for not being vaccinated. The individual must declare that all information provided is true and acknowledges consequences for falsifying details.

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Real Nurul
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319 views3 pages

Health Declaration Form

This document is a health declaration form that collects an individual's personal details and medical history. It asks for information such as name, age, address, medical conditions, operations, accidents, illnesses, and pregnancy status. It also includes a COVID-19 health record section asking about vaccination status, test results, and reasons for not being vaccinated. The individual must declare that all information provided is true and acknowledges consequences for falsifying details.

Uploaded by

Real Nurul
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

HEALTH DECLARATION FORM

NAME:_________________________________ SEX : ___________ AGE : ______

NRIC NO. : ____________________________________TEL : __________________

ADDRESS:____________________________________________________________

MEDICAL HISTORY

Description Reply Description Reply


Asthma Yes / No Sinus Yes / No
Diabetes Yes / No Epilepsy Yes / No
High Blood Pressure Yes / No Mental Disorder Yes / No
Tuberculosis Yes / No Colour Blind Yes / No
Migraine Yes / No Thyroid Yes / No
Heart Disease Yes / No Genetic Disorder Yes / No
Anxiety Yes / No

Have you ever gone through operation? Yes / No


Have you ever been involved in an accident? Yes / No
Are you suffering from any in-born disease or physical impairment? Yes / No
Have you ever been hospitalized? Yes / No
Do you have any other illness? Yes / No
Are you currently pregnant (Applicable to female only)? Yes / No

(Please provide details if your reply to the above question/(s) is “Yes”)

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________
COVID-19 HEALTH RECORD

Have you registered for the national COVID-19 Immunisation Program appointment?
Yes / No

Please fill in the below if your reply is “Yes”

Location
(Venue & State)

Not Yet Vaccinated Vaccinated (Date)


Did not receive Type of
Received Vaccination
any Vaccination 1st Dose 2nd Dose 3rd Dose Vaccine
Date
Date
Yes / No Yes / No

Please fill in the below if your reply is “No” - Reason

_______________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

For the past 90 days, have you been tested positive or suspected to be positive with
Covid-19 : Yes / No

(Please provide details if your reply to the above question is “Yes”)

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________
I hereby declare that the above information is true and to the best of my knowledge and
belief. I understand that if I were found to have falsified the above information, the
Company may take such action as it deems fit against me including but not limited to the
termination of my service without notice.

__________________________

Name:
NRIC No.:
Date:

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