CCR Health Check Form & Informed Consent

Date & Time:__________________________________________________

Name: ________________________________________________________

Biometric number: __________________________ Company:__________

Contact Phone Numbers: ______________________ Age: _____________

Height: _______________Weight: _____________ BP:________________

BMI:_____________ Gender:___________ Nationality:________________

Allergies:______________________________________________________

Urine Labstix:
Glucose: _____________________

Ketones: _____________________

Protein: _____________________

PH: _____________________

Blood: _____________________

What is your occupation?________________________________________

Length of work in Singapore?____________________________________

Next of Kin information?________________________________________

Informed consent to release health information

I hereby consent to participate in health check and release your health
information to be shared within the CCR Wellness Steering Committee.
Your health information will held strictly confidential and will only be shared for
the benefit of the participant and group as a whole.

Name: Signature
(Participant)

Name: Signature
(Witness)

Date:__________________________________