MEDICAL REPORT (2014) - Singapore Polytechnic

Medical Report Form
MEDICAL REPORT (2014)
Admission Number
(This medical report will not be returned to the student)
This form may take you 3 minutes to fill. The data provided will be kept strictly confidential and used for the purpose of assessing fitness 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 deficiency, you should not pursue the following courses:
- Applied Chemistry with
- Chemical Engineering
Pharmaceutical Science
- Electrical & Electronic Engineering
- Biomedical Science
- Engineering Systems
- Biotechnology
@Student must pass the Maritime and Port Authority of Singapore Sight Test.
- Food Science & Technology
- Marine Engineering
- Nautical Studies @
• If you are suffering from either colour vision deficiency 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 deficiency, 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
A Personal Particulars
Name:
Date of Birth:
Tel:
NRIC / Foreign Identification:
Course:
Handphone:
Gender: Male / Female
B Medical Information
1. Family Doctor / Clinic:
Tel:
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):
Yes
No
No
Yes
Autism / Asperger Syndrome
Hearing Loss
Allergies
Colour Vision Deficiency
HIV Positive / AIDS
Asthma
Diabetes
Hypertension
Attention Deficit Hyperactivity
Disorder (ADHD / ADD)
Dyslexia
Psychiatric Condition
Epilepsy
Vision Loss (excluding myopia)
Other Medical Conditions:
Yes
Active Tuberculosis
No
Other Physical Disability:
(#) Details:
3. Please provide your Family, Social and Drug history by checking below. If your answer is 'Yes', give details.
Yes
No
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
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:
Date:
Name :
Admission No :
Course :
PART 2 – TO BE COMPLETED BY A MEDICAL PRACTITIONER REGISTERED IN SINGAPORE ONLY
Height (m) :
Weight in kg
BMI = ------------------(Height in m)
2
Weight (kg) :
If BMI > = 23 (moderate high risk)
BMI :
Acuity of Vision
R
L
Urine Analysis:
Glucose
Protein
Blood
Colour Vision (tick one only)
Ishihara Test
Normal
Without glasses
With glasses
Partial: Red / Green deficiency
History of Epilepsy:
Yes
No
Complete: Red / Green deficiency
If yes,
Recovered
Still on Medication
Chest X-Ray Report:
PHYSICAL EXAMINATION
Eyes :
Ears :
Nose :
Teeth :
Gums :
Tonsils :
Back / Spine :
Injury, Operation, Illness:
Blood Pressure :
Pulse :
Heart :
Abdomen & Pelvis :
Hernia (Enlarged Rings) :
Skin :
Mental Disposition :
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 fitness 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 :
Certification of Fitness
1.
I have today completed a medical examination of the person named overleaf and find this student for admission to be
free / not free* from organic and infectious diseases.
2.
The student is physically and mentally
• Fit / Unfit* to pursue the course indicated.
• Fit / Unfit* to pursue Any Other Course / Other Courses*
Remarks (if any) :
* Please delete accordingly. The student is deemed unfit unless certified fit.
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 fit / unfit* to be employed on board ship as Cadet Engineer / Engineer Officer.
•
Diploma in Nautical Studies Course
The student is fit / unfit* to be employed on board ship as a Cadet Deck Officer.
Name of Registered Medical Practitioner:
Qualifications:
(Signature of Doctor)
Name and Address of Practice:
Date:
(OFFICIAL STAMP)
Medical Check-Up and X-Ray for Full-Time Courses
•
Successful Applicants of all Full-Time courses are required to undergo a medical
check-up and X-ray.
•
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 check-up. Should you choose this option,
please submit your medical report personally at Student Service Centre (Blk T16 Level
1) or mail in to Admissions Office, 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
check-up at the clinics listed will have their SP Medical Report dispatched to us by the
clinics.
•
All full-time international students are required by the Immigration & Checkpoints Authority
(ICA) to undergo a medical check-up with HIV testing. Please have both the SP and ICA
Medical Examination Report Forms when you go to the clinic for your medical check-up.
You will have to collect the ICA medical report from the clinic when it is ready.
•
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 Office immediately should you have a medical
condition that prohibits you from pursuing the offered course (e.g. colour vision
deficiency). SP will need to arrange for a course transfer.
Call 6772-1882 or email [email protected] with Subject Title: Medical
Condition and provide your Name, Admission Number and Course Offered.
Clinics
Opening Hours
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
(One-Stop Centre with X-Ray Services)
351 Chai Chee Street
Singapore 468982
Tel: 6244-6688
MRT Station: Bedok
Bus Service:
222 (from Bedok MRT Station, in front of Blk 27, New Upper Changi Road)
Monday To Friday
8.30 am to 5.00 pm
SATA Jurong Medical Centre
(One-Stop Centre with X-Ray Services)
Blk 135 Jurong Gateway Road
#04-345
Singapore 600135
Tel: 6244-6688
MRT Station: Jurong East
Bus Service:
51, 66, 78, 79, 97, 98, 105, 197, 331
Monday To Friday
8.30 am to 5.00 pm
SATA Woodlands Medical Centre
(One-Stop Centre with X-Ray Services)
900 South Woodlands Drive
#04-01 Woodlands Civic Centre
Singapore 730900
Tel: 6244-6688
MRT Station: Woodlands
Bus Interchange:
161, 168, 169, 178, 187, 856, 858, 900, 900A, 901, 902, 903, 911, 912, 913, 925,
926, 950, 960, 961, 962, 963, 963E, 964, 965, 966, 967, 968, 969, 970, 971
Monday To Friday
8.30 am to 5.00 pm
SATA Ang Mo Kio Medical Centre
(One-Stop Centre with X-Ray Services)
Blk 715 Ang Mo Kio Avenue 6
#01-4008 / 4010
Singapore 560715
Tel: 6244-6688
MRT Station: Ang Mo Kio
Bus Interchange:
13, 86, 138, 162, 851, 852, 853
Monday To Friday
8.30 am to 5.00 pm
Saturday
8.30 am to 1.00 pm
Weekend Surcharge: S$8.00
Closed on Sundays & Public Holidays
Saturday
8.30 am to 1.00 pm
Weekend Surcharge: S$8.00
Closed on Sundays & Public Holidays
Saturday
8.30 am to 1.00 pm
Weekend Surcharge: S$8.00
Closed on Sundays & Public Holidays
Evening Clinic
6.00 pm to 9.00 pm
Surcharge: S$5.00
Saturday
8.30 am to 1.00 pm
Weekend Surcharge: S$8.00
Closed on Sundays & Public Holidays
• Singaporean / Permanent Resident: S$28.00 (inclusive of 7% GST)
• International Student: S$47.50 (inclusive of 7% GST)
Ang Mo Kio – Thye Hua Kwan Hospital
17 Ang Mo Kio Avenue 9
Singapore 569766
Tel: 6454-8481
MRT Station: Yio Chu Kang
Bus Service:
76, 265, 268
Monday To Thursday
8.45 am to 3.30 pm
Lunch (Closed):12.00 noon to 2.00 pm
Friday and Saturday
8.45 am to 12.00 noon
Closed on Sundays & Public Holidays
Last appointment for AM session is at 11am
Last appointment for PM session is at 3 pm

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