PART 2 - MEDICAL HISTORY REPORT
( To be filled in by examining doctor )
NAME OF APPLICANT: ____________________________
NRIC / PASSPORT NO: _____________________________
HOME
TELEPHONE NO: __________________________________
ADDRESS:
__________________________________
This course is strenuous in nature and may require the trainee to don personal protective equipment, breathing apparatus etc in
confined space during the training process. The purpose of these questions is to ensure that the trainee does not have any medical
condition which would place him/her at an increased risk during training.
HAVE YOU EVER HAD OR DO YOU NOW HAVE: ……………. Please mark each item below “Yes” or “No”. All
“Yes” items must be fully explained in Para 10
Yes
1a. Asthma or any breathing problems related
to exercise, weather pollens, etc.
b. Shortness of breath
c. Bronchitis
d. Wheezing or problems with wheezing
e. Sinusitis
2a.
b.
c.
d.
Painful shoulder, elbow or wrist
Recurrent back pain or any back problem
Foot trouble (e.g. pain, corns, bunions, etc)
Knee trouble (e.g. locking, giving out,
pain or ligament injury, etc)
e. Bone, joint, or other deformity
f. Broken bone(s)(cracked or fractured)
3a.
b.
c.
d.
Stomach, liver, intestinal trouble, or ulcer
Gall bladder trouble or gallstones
Jaundice or hepatitis (liver disease)
Rectal disease, hemorrhoids
or blood from the rectum
Frequent or painful urination
High or low blood sugar
Kidney stone or blood in urine
Sugar or protein in urine
e.
f.
g.
h.
4a. Pain or pressure in the chest
b. Palpitation, pounding heart or abnormal heartbeat
c. Heart trouble or murmur
d. High or low blood pressure
5a.
b.
c.
d.
Dizziness or fainting spells
Frequent or severe headache
A head injury, memory loss or amnesia
Seizures, convulsions, epilepsy or fits
No
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Yes
6a. Nervous trouble of any sort (anxiety
or panic attack)
b. Loss of memory or amnesia, or
neurological symptoms
c. Depression or excessive worry
d. Been evaluated or treated for a mental
condition
7.
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Have you ever been a patient in any
type of hospital?
No
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If yes, please specify when, where and why:
_________________________________________
_________________________________________
8.
FEMALES ONLY. Have you ever had or do you
now have:
a. Treatment for a gynecological (female)
disorder
b. A change of menstrual pattern
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Have you ever had any illness or injury
other than those already noted?
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9.
If yes, specify when, where and give details:
_______________________________________
_______________________________________
10. If any of the above answers is “Yes”, please provide explanation below .
___________________________________________________________________________________________________
___________________________________________________________________________________________________
EXAMINED BY:
NAME OF DOCTOR: _____________________________________
SIGNATURE & STAMP::_________________________
NAME OF HOSPITAL / CLINIC: ____________________________
ADDRESS: ___________________________________
DATE: ______________________________________________
TELEPHONE: ___________________________________