MEDICAL EXAMINATION REPORT

Instructions
• This Medical Examination Report is to be completed by a Registered Medical Practitioner and returned to the
student. The original copy of the laboratory reports and chest X-ray reports must be attached to the Medical
Examination Report.
• For students in Singapore, medical examination must be done by a Registered Medical Practitioner in
Singapore.
• For students in Malaysia, medical examination, laboratory test and X-ray must be done in a hospital / clinic of
Parkway Pantai Limited.
• For students in other countries, medical examination must be done by a Registered Medical Practitioner in their
home countries or places of residence. Students who are accepted for the course will repeat the Medical
Examination by a Registered Medical Practitioner in Singapore after they have arrived here for the course.
• The completed Medical Examination Report must be submitted to Parkway College, 168 Jalan Bukit Merah,
Tower 3, #02-05, Singapore 150168.
PART A: TO BE COMPLETED BY STUDENT
Personal Particulars
Full Name: NRIC/Passport/FIN No.:

Course: Nationality:

Date of Birth: Gender: M/F Tel/Handphone:

Contact Address:

Personal Medical Record

Have you ever had, or do you have any of these medical conditions? Please tick ‘Yes’ or ‘No’ in all the empty boxes.
Yes No Yes No Yes No
Asthma Vision Loss Physical Disability
Diabetes Hearing Loss Any Surgical Operations
Hepatitis B/C Tuberculosis (TB) Dyslexia
Allergies Gastric Problems Autism/Asperger’s Syndrome
AIDS/HIV Positive Heart Problems Attention Deficit Hyperactivity
High Blood Pressure Kidney Problems Disorder (ADHD)

Blood Disorder Chronic Skin Disease Medical Implants (clips,

Eating Disorders Epilepsy/Fits stents, dental implants, etc)

Others Psychiatric Conditions

If your answer is ‘Yes’ to any of the above boxes, please provide further details below or attach supporting documents (if
any):

Family Medical Record

Do any of your parents or sibling(s) have any of these medical conditions? Please tick ‘Yes’ or ‘No’ in all the empty boxes.
Yes No Yes No Yes No
Diabetes Psychiatric Conditions Tuberculosis
Hepatitis B/C Paralysis or Stroke Heart Problems
High Blood Pressure AIDS/HIV Positive Kidney Problems

Any other information:

I hereby declare that all the information provided is true and accurate to the best of my knowledge and I have not deliberately
omitted any relevant fact(s). I consent for my / my child’s / my ward’s medical examination and test results to be released to
Parkway College of Nursing and Allied Health Pte Ltd for the purpose of processing my application. Should I / my child / my
ward be admitted to Parkway College of Nursing and Allied Health Pte Ltd on the basis of the information given in this report
which may later turn out to be false or inaccurate, I understand that I will render myself / my child / my ward liable to appropriate
disciplinary action, including dismissal from the course.
I am aware that I / my child / my ward will need to be screened for blood borne diseases (Hepatitis B, Hepatitis C, HIV) and
undergo immunisation against Hepatitis B, Chicken Pox, Mumps, Measles, Rubella and Pertussis. The cost for these tests
and vaccinations will be borne by me.
Signature of Student/Date: Signature of Parent or Guardian/Date:
(For students under the age of 18 years)

FORM/SA/04
Version 2.5 dated 15 June 2017 Page 1 of 4
 PART B: TO BE COMPLETED BY THE EXAMINING DOCTOR

Height (m): Urine Labstick (Glucose) Positive / Negative

Weight (kg): Urine Labstick (Protein) Positive / Negative
BMI: Urine Pregnancy Test ( for Positive / Negative
females only)

Acuity of Vision: R L Colour Vision (Ishihara Test):

Glasses/Contact Lens Normal
No Glasses/Contact Lens Partial Colour Blind
Complete Colour Blind

Remarks: Types of Colour Blindness:

Chest X-ray: Normal / Abnormal* History of Epilepsy: No / Yes*

Remarks: Remarks:

Pulse: Back/Spine:
Blood Pressure: Injury, Operation or Illness:

Immunity Status
Documentary evidence of serological tests and/or vaccination dates is compulsory. This table must be duly completed.
Varicella (Chicken Pox) Mumps, Measles & Rubella (MMR)

Immune Not Immune Immune Not Immune

Date of Serological Test: Date of Serological Test:

OR OR
Vaccination Dates: Vaccination Dates:

OR
History of Chicken Pox based on physician’s
diagnosis

Hepatitis B Pertussis

Immune* Carrier Vaccinated Not Vaccinated

Not Immune

Date of Serological Test: Vaccination Dates:

Tetanus toxoid, reduced diphtheria toxoid and acellular

Vaccination Dates (if any):
pertussis (Tdap) vaccination:
The vaccination should have been done within the last 5
years. Vaccination is valid for 10 years.

*A previous post-vaccination record of Anti-HBs Ab ≥

10mIU/mL is acceptable evidence of Immunity.

FORM/SA/04
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Other Tests
Hepatitis C HIV

Reactive Carrier Reactive

Non-Reactive Non-Reactive

Date of Serological Test: Date of Serological Test:

Serological test is valid for up to 6 months Serological test is valid for up to 6 months

Certification of Fitness

1) I have today completed a medical examination of this student. I find him/her to be

Free / Suffering* from organic and infectious diseases
2) The student is physically & mentally

Fit / Unfit* to pursue the selected course of study at Parkway College of Nursing and Allied Health Pte Ltd.

Vaccinations required and remarks, if any

*Delete where appropriate. The student is deemed unfit unless certified fit.

Name of Doctor: Signature of Doctor:

Name and Address of Practice (Stamp): Date of Medical Examination:

FOR OFFICIAL USE ONLY

Name Signature Date

By Programme Lead
Student is accepted / not accepted
for the course

Due Date
By Course and Student Admin
(as decided by Programme Completion Date Signature
Follow-up on required vaccinations
Lead)
1. Hepatitis B Vaccination (post
vaccination serologic testing 6
weeks after 3rd dose)

2. Hepatitis B Booster (post

booster serologic testing 6
weeks after booster dose)

3. Chicken Pox

4. MMR

5. Pertussis

FORM/SA/04
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 MEDICAL REQUIREMENTS FOR NURSING AND RADIOGRAPHY COURSES

1. Students for the Nursing and Radiography course will have to pass a medical examination
and be certified to have the following abilities to perform patient care activities in a safe
and effective manner:
a. Mental ability (interpersonal ability and behavioural stability) to provide safe care
to populations, as well as safety to self, and demonstrate self-control and
behavioural stability to function and adapt effectively and sensitively in
a dynamic role.
b. Physical ability to move around in clinical environment, walk/stand, bend, reach,
lift, climb, push and pull, carry objects and perform complex sequences of hand
eye coordination.
c. Auditory ability to hear faint body sounds, auditory alarms and normal speaking
level sounds (i.e. blood pressure sounds, monitors, call bells and person-to-
person report).
d. Visual ability to detect changes in physical appearance, colour and contour, read
medication labels, syringes, manometers, and written communication accurately.
2. All students must pass a medical examination and be free from physical handicap to
ensure suitability. Students with the following medical conditions will not be accepted for
the nursing and radiography courses:
a. Legal blindness
b. Active tuberculosis
c. Profound deafness
d. Psychiatric condition
e. Uncontrolled asthma
f. Uncontrolled epilepsy
g. Uncontrolled diabetes
h. Uncontrolled hypertension
i. Mobility restricted (hindering performance)
j. Physical dependence upon mobility equipment
3. In accordance with the Singapore Ministry of Health (MOH) requirements, it is compulsory
for all Nursing and Radiography students to be screened for the following blood-borne
diseases:
a. Hepatitis B
b. Hepatitis C
c. HIV
4. Students who are screened and found to be Hepatitis B or Hepatitis C carriers or HIV
positive will not be accepted for the nursing and radiography courses.
5. Students are required to go for immunisation against Hepatitis B if found to be non-
immune: three doses at 0 month, one month and six months. The 1st dose is to be done
within 1 month of course commencement. The student’s blood will be re-tested 6 weeks
after completion of the 3rd dose.
6. Students are also required to go for Chicken Pox, Pertussis and MMR vaccinations within
3 months of course commencement, if they have not been vaccinated or are found to be
non-immune.
7. Please bring your health booklets (for Singaporeans) or any other documentary proof of
vaccination records to the medical centre.

FORM/SA/04
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