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PSA Health Declaration Form Sep2022

The document is a health declaration form that requires the applicant to answer various health-related questions, including past illnesses, hospitalizations, and current treatments. The applicant, Khor Yean Sum, certifies the accuracy of the information provided and acknowledges the consequences of providing false information. The form includes a signature line and date for the applicant's confirmation.

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Dino TT
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3 views

PSA Health Declaration Form Sep2022

The document is a health declaration form that requires the applicant to answer various health-related questions, including past illnesses, hospitalizations, and current treatments. The applicant, Khor Yean Sum, certifies the accuracy of the information provided and acknowledges the consequences of providing false information. The form includes a signature line and date for the applicant's confirmation.

Uploaded by

Dino TT
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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HEALTH DECLARATION FORM

Yes No If Yes, please provide details


1 Have you ever been diagnosed of any major
illness or sickness ?
2 Have you ever been hospitalised ?
3 Are you taking or retrieving any form of
treatment now ?
4 Do you smoke ?
5 Do you consume alcohol ?
6 Do you have any allergies ?
7 Have you ever abuse drugs ?
8 Have any of your family members ever suffered
from any major illness or sickness ? Diabetes
9 Have you ever suffered or had the following : -
a. Fits/headaches/faints/paralysis/mental
disorder
b. Any complaint of the eyes, ears, nose or throat
c. Persistent or unexplained fever, sweats or
Gout
weight loss/gain
d. Difficulty breathing, coughing or spitting of
blood
e. Palpitations, chest pain, high blood pressure
f. Persistent joint pains, swelling and stiffness
g. Persistent or recurrent abdominal
complaints/jaundice
h. Micturition difficulties or pain
i. Diabetes mellitus/gout
j. Abnormal pregnancy/menstrual problems
k. Other complaints/conditions not stated above

I KHOR YEAN SUM (Fullname as in NRIC/Passport), 920922146703


(NRIC/Passport No) declare that all the information given by me in this application for employment and
any additional documents attached hereto are true to the best of my knowledge and that I have not
wilfully suppressed any material fact. I accept that if any of the information given by me in this
application is in any way false or incorrect, my application may be rejected, any offer of employment
may be withdrawn or my employment with the Service may be terminated summarily.

By signing below, I hereby certify that I have read and understood all the clauses above and that I agree
to all of them.

15/08/2024
Signature of Applicant : ______________________ Date :

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