TANGLIN SECONDARY SCHOOL

HEALTH DECLARATION FORM

Name: _______________________________ ( ) Class: ______________________

No Medical Condition No Yes If yes, please provide further information

1 Do you have heart problems?
Including Chest pains, high blood pressure or heart
problems e.g. heart murmur, extra heartbeat, mitral
valve prolapse or any other heart problems.
2 Do you have lung problems?
Including asthma, bronchitis, tuberculosis, sinusitis
or other lung problems
3 Do you suffer from fits, epilepsy, fainting spells,
migraine, severe head injury?
4 Do you have any vision problems, including eye
problems and poor vision?
5 Do you have any ear problems, including hearing
difficulty?
6 Are you suffering from any nervous illness?
7 Are your suffering from Diabetes / Thalassaemia
major / Anaemia?
8 Do you have allergy to medicines / food / others
e.g. sea water, insect bites? Pls include skin injury
9 Have you had any bone or joint injuries e.g.
fracture / dislocation?
10 Are you on routine medication?
11 Do you have any special diet requirements?
12 Do you have any form of disability?
13 Do you have any other medical information of note
e.g. Specialist’s letter/note (pls attach)

I declare that the above information is correct.

__________________________________________ _______________________
Signature / Name of parent Date

In case of emergency:
Name of contact person: ______________________________________ Relation: ______________________

Contact number: ____________________ (Home) ______________________ (HP)

Prepared by: Mr Philip Wan

CCA Dept