DSO Pre-Employment Medical Risk Assessment

DSO

Pre-employmentRe-employmentTransfer

This questionnaire will only be used for purpose of assessing fitness to work in DSO. The questionnaire meets the US HIPAA (Health Insurance Portability & Accountability Act) requirements for medical information. A password protected FILLED copy will be sent to you after submission.

Name (According to NRIC/FIN/Passport)

NRIC/FIN

Job Title

Date of Birth

Date

Current Age (years)

Gender

MaleFemale

Handphone

Past Occupational History (list job designation, years, type of lab and work-related injuries/diseases)

Have you ever had, or do you now have or suffer from any of the following:

	No	Yes	Elaborate	Dr Comments
Work-related injury/disease/exposure previously
Prescription spectacles/contact lens
Eye or visual problem
Deafness or ringing noise in ear
Ear infections or discharge from ear
Other ear, nose or throat problem
Convulsions, fits or epilepsy
Head injury or Concussion
Severe depression
Claustrophobia
Mental illness
Heart disease
High blood pressure
Pain or discomfort in the chest on exertion
Shortness of breath on exertion
Need to use inhaler or puff
Operation in chest, lungs or heart
Bronchitis or pneumonia
Chronic or persistant cough
Pneumothorax
Asthma or wheezing
Other chest complaint
Jaundice, hepatitis or liver disease
COVID infection
Severe loss of weight
Back Injury
Musculoskeletal Injury/fracture/dislocation
Limitation of movement
Paralysis or muscle weakness
Kidney or bladder disease
Diabetes
Bleeding problem or other blood disease
Skin disease
Contagious disease
Operations
Admitted to hospital
Rejected for life insurance
Failed medical examination
Unable to work on medical grounds
Autoimmune disease
Taking steroids or immunosuppressive medication
Any other illness or health problem
Family history of heart disease, diabetes
Females only: Are you pregnant or planning to be in next 6 months?

Vaccinations

	No	Yes	Dates
Hepatitis B (to do antibody titres under Dates)
Tetanus
Hepatitis A
Influenza (Flu)
Measles, mumps, rubella (MMR)
Tetanus, diptheria, pertussis (Tdap)
Chickenpox
Smallpox
Others (list vaccines under Dates)

Healthy Lifestyle Habits

	No	Yes	Details
Smoker (Please list number of cigarettes/vap per day)
Exercise less than 3 times per week
Drink alcohol at least 2 times per week

Declaration

I certify that the above information is true and complete to the best of my knowledge.I authorise the clinic to obtain or supply medical information regarding me to other doctors as may be necessary for the medical assessment.I consent to providing my medical information to my employer regarding to my fitness to work.

Signature

Date

Date of Consultation

Date

PHYSICIAN COMMENTS ON HISTORY

Height (m)

Weight (kg)

BMI (Satisfactory/Abnormal)

Urine Dipstick

NORMALAbnormal. Details:

Visual Acuity

	Uncorrected	Corrected
Right - Far
Left - Far
Right - Near
Left - Near

Colour Perception (Ishihara Chart)

NormalPartial Colour DeficiencyTotal Colour Deficiency

Above tests conducted by:

General Appearance

Blood Pressure (mmHg)

Pulse (/min)

Systemic Review

	Normal	Abnormal	Notes
Eyes
ENT screen
Cardiovascular system
Respiratory system
Abdomen
Central nervous system
Skin
Lymph nodes
Posture & gait
Musculoskeletal system
Emotional & Psychiatric stability
Others

Summary of Findings/Investigations

	NA	Satisfactory	Abnormal	Notes & Comments
Biosafety Health Risk Assessment
Respirator Health Risk Assessment
Animal Work Health Risk Assessment
Chemical Warfare Agents Health Risk Assessment
Physical Examination
Visual Acuity
Color Vision
Spirometry
Audiometry
Chest Xray
Resting Electrocardiogram
Full Blood Count
HBA1C/ Fasting Glucose
Urine Dipstick
Plasma Cholinesterase
RBC Cholinesterase
Hepatitis B Screen/Titres
Hepatitis A screen
Tetanus vaccine
Liver/Renal function
Other Investigations

Other Tests

Nil requiredIndicated. Specify:

The abovementioned is assessed for fitness for DSO employment in the following areas:

Certification

Physician Comments

Presence of medical condition that would place the abovementioned at an increased risk of performing his/her work duties. The abovementioned has been informed of the risk:

NoYes

For protection of his/her health & safety, the following is advised by the physician:

Validity

1 Year2 YearsChange in medical statusOther

Dr Gregory Chan Chung Tsing, PPA(G), PP

MBBS, MMED Occup Med, GDip Geriatric Med, GDip FP Derm, Cert DHM (Adelaide, Toronto), DWD (All hazards)

Senior Specialist Physician, Occupational Medicine

MCR: M06367C

Signature of OM Specialist

Date of Certification

Date

Time

Hour Minutes

AM/PM Option