Medical Self Declaration Form

Medical Self Declaration Form Template for Singapore

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Key Requirements PROMPT example:

"I need a Medical Self Declaration Form for my private medical clinic in Singapore, compliant with MOH guidelines, that includes sections for COVID-19 vaccination status and cHRonic disease history."

Document background

The Medical Self Declaration Form is a crucial document in Singapore's healthcare and regulatory framework, designed to capture accurate health information from individuals. This form is commonly required for medical procedures, insurance applications, employment purposes, or institutional requirements. It must comply with Singapore's healthcare legislation, including the PDPA and Healthcare Services Act. The form typically includes current health status, medical history, ongoing treatments, and any relevant health conditions that need to be disclosed.

Suggested Sections

1. Personal Information: Basic identification details including full name, NRIC/FIN, date of birth, gender, and contact information

2. Medical History Declaration: Comprehensive section for declaring current and past medical conditions, medications, surgeries, and ongoing treatments

3. Lifestyle Factors: Declaration of relevant lifestyle factors such as smoking, alcohol consumption, and exercise habits

4. Data Protection Notice: PDPA-compliant notice explaining how personal and medical data will be collected, used, and protected

5. Declaration of Truth: Formal statement confirming that all provided information is true and accurate, with acknowledgment of legal implications for false declarations

Optional Sections

1. Emergency Contact Information: Optional section for providing emergency contact details, typically used in clinical settings or employer requirements

2. Insurance Information: Details of medical insurance coverage, required when form is used for insurance or healthcare financing purposes

3. COVID-19 Declaration: Specific declarations related to COVID-19 exposure, vaccination status, and symPTOms, included when required by current health protocols

4. Family Medical History: Section for declaring hereditary conditions and family health history, used in comprehensive medical assessments

5. Travel History: Recent travel declarations, particularly relevant during infectious disease outbreaks or pandemic situations

Suggested Schedules

1. Schedule A: Medical Conditions Checklist: Comprehensive checklist of medical conditions and diseases for systematic declaration

2. Schedule B: Privacy Policy: Detailed privacy policy and data protection information in compliance with PDPA requirements

3. Schedule C: Medical Terms Glossary: Definitions and explanations of medical terms used in the form to ensure clear understanding

4. Schedule D: Consent Forms: Additional consent forms for specific medical information sharing or verification processes

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok��˰� | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare
Insurance
Corporate
Education

Relevant Teams

Human Resources
Medical Administration
Legal
Occupational Health
Compliance
Risk Management

Relevant Roles

Human Resources Manager
Medical Officer
Insurance Underwriter
Occupational Health Officer
Compliance Officer
Risk Manager

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Authors

Alex Denne

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