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China 
Japan 
Indonesia Magicsoft Asia
Project :
Health Declaration by Workers
A. Personal Particulars
Name : test
NRIC/FIN No. : test
Date of Birth : 09/08/2000
Nationality : test
Sex : Male
Height : test
Weight : test
Contractor : Magicsoft Asia
Trade : test
| B. Medical History/ Health Problem | Yes / No | If Yes, give brief details |
| Mental Illness (Disorder behaviour/ thinking) e.g. anxiety, depression | Yes | |
| Heart Disease/ heart attack, chest pain | Yes | |
| Color Blindness/ difficult in distinguishing colors | Yes | |
| Night Blindness/ trouble seeing in dim light | Yes | |
| Short Sightedness /cannot see far | Yes | |
| Long Sightedness/ cannot see near | Yes | |
| Diabetes/ high blood sugar | Yes | |
| Dermatitis/ skin itchiness, red skin | Yes | |
| Hypertension/ high blood pressure | Yes |
| Noise induced deafness (NID)/ hearing problem | Yes | |
| Dengue fever/ Zika disease | Yes | |
| Taking medication | Yes | |
| Accident/ existing physical injury/ operation/ surgery | Yes |
| Other : | Yes |
1. I declare that all the information given above is true & correct.
2. I hereby give my consent for a copy of this health declaration form after it is completed to be released to my employer and occupier of the
worksite.
Signature of Worker Date
Admin
09/08/2018
Name & Signature of Witness Date