TAYLOR'S INTERNATIONAL SCHOOL

PERSONAL HEALTH DECLARATION

N.B. It is important to note that the employee must disclose fully all facts relating to illnesses, injuries and treatment received prior

to employment and subsequent thereafter prior to confirmation of service, failing which the Company reserves the right to

terminate his/her services without notice.

1) Name: __________________________________________________________ Sex: _________________________________

Date of Birth: _____________________________________________________ NRIC No. _____________________________

2) Have you had any physical defects? Yes No

If "Yes", give details _________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

3) Have you ever:

a) had a surgical operation?

b) been advised to have a surgical operation that was not performed? Yes No

If "Yes" in either case, give particulars in question (6)

4) Have you ever been treated for, under observation for, or told that you had any of the following:

Yes No Yes No

a) Epilepsy (Giddiness) or Vertigo ? o) Hernia or Rupture ?

b) Syphilis ? p) Sciatia or Lumbago ?

c) Diabetes or Goitre ? Diseases of the :

d) Gout or Kidney Trouble ? q) Heart or Lungs ?

e) Arthritis ? r) Eyes or Ears ?

f) Rheumatism or Rheumatic Fever ? s) Throat or Nose ?

g) Mental Disorder ? t) Brain or Nervous System ?

h) Varicose Veins ? u) Genito-Urinary System ?

i) High or Low Blood Pressure ? v) Bones or Joints ?

j) Cancer or Tumor ? w) Blood Vessels ?

k) Ulcer of stomach or intestine ? x) Stomach or Intestines ?

(Peptic ulcer)

l) Tuberculosis ? y) Gall Bladder or Liver ?

m) Asthma ? z) Skin or Glands ?

n) Haemorrhoids (Piles) ?

5) Have you during the past 5 years, had any treatment, examination or advice, by a physician or other medical practitioners, at a clinic, hospital,

or sanitorium ?

Yes No

(Please give particulars of each such instance in question (6) below)

6) State full particulars of any affirmative answers to questions (3), (4) & (5).

Nature & Date Name & Address of

Question No. of Disability For How Long Result of Treatment Doctors & Hospitals

___________ ___________________ ___________________ __________________________ _____________________________________

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___________ ___________________ ___________________ __________________________ _____________________________________

___________ ___________________ ___________________ __________________________ _____________________________________

___________ ___________________ ___________________ __________________________ _____________________________________

___________ ___________________ ___________________ __________________________ _____________________________________

___________ ___________________ ___________________ __________________________ _____________________________________

7) Have you ever used regularly any habit forming drops or narcotics or used alcohol excessively ?

Yes No

I hereby declare that the foregoing statements and particulars are true and complete. I have not withheld any information

that may influence my employment, and I agree that this declaration shall form part and parcel of my contract of service

with TAYLOR'S INTERNATIONAL SCHOOL. I further declare that it is hereby understood and agreed that should

any of the above statements be found to be false or incorrect, the Company reserves the right to terminate my services

without notice.

___________________________ ___________________________________

Date Signature of Employee

NRIC No. ___________________________

Yes