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MALAYSIA PUBLIC POLICY COMPETITION 2014

HEALTH DECLARATION FORM



NAME : _______________________________________

TEAM NAME : _______________________________________

NRIC : _______________________________________

Conditions *Yes/No
1
Do you have any pre-existing illness or suffer from any
allergy? E.g. asthma, diabetes, epilepsy, hernia, dizziness,
circulatory problems, heart condition, high blood pressure,
rheumatic fever, stroke, high cholesterol, palpitations,
murmurs and/or pains in chest?


If yes, please specify:

2 Do you have any drug allergy? *Yes/No If yes, please specify:

3 Are you taking any prescribed medication? *Yes/No
For items marked with *, delete where inapplicable
If yes, please specify:


All information will not be disclosed and shall only be circulated internally for administrative
purposes. If you have answered YES to any of the questions above, please provide details. In the
event of medical emergencies, this form would be provided to the doctor.

Participant Name: _____________________________
Participant Signature: _________________________________
Date: _______________________

*Kindly fill up and pass to your team leader who will then submit this form by the 4th August 2013
in a SINGLE email.

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