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.
Managing Diabetes: Understanding and Controlling Type 1, Type 2, and Gestational Diabetes, Practical Strategies for Blood Sugar Management and Lifestyle Adaptation: The Comprehensive Health Series