Child's Details

Name: LIN JIAXU, LUCAS

NRIC/BC/FIN: T1108811I Date of Birth: 25-03-2011

Medical History
Does your child/ward have any of the following conditions?
Asthma No

Epilepsy No

Fits due to high fever No

Kidney Disease No

Heart Disease No

Diabetes Mellitus No

Blood Disease No

Operation No

G6PD Deficiency Yes

Year of Diagnosis: 2011

Is follow up required? No
Follow-up Institution: Thomson Medical Centre
Date of Last Appointment: 2011
Current Medication if Any: N.A

Details of Medical Condition: G6PD deficiency diagnosed at birth. No follow up or medicine

required.

HepB/HepB Carrier No

Eye Condition Yes

Year of Diagnosis: 2014

Is follow up required?
Follow-up Institution:
Date of Last Appointment:
Current Medication if Any:
Details of Medical Condition:
No
Private Medical Practitioner
09-12-2017
Diagnosed with anisometropia and amblyopia.

Currently wearing Glasses.

Others No

Drug / Other Allergies

Is your child / ward allergic to any of the following?

a) Drugs / medicines No

b) Immunisations No

c) Food No

d) Others No
Consent for Immunisation(Valid for one year from the date of submission)
Please note that immunisations against diphtheria and measles are COMPULSORY by law in Singapore.

YES, I consent to my child / ward receiving the age-appropriate immunisation(s) : Oral Sabin (against Polio), Tdap (against
Tetanus, Diphtheria and Pertussis) and MMR (against Measles, Mumps and Rubella) from the School Health Service. This is in
accordance with Singapore's National Childhood Immunisation Schedule. I understand that the immunisation(s) will only be
given if my child / ward is due for the immunisation(s) or has missed earlier dose(s).

My child is left handed. Please give injection in right arm.

Immunisation Questionnaire
Has your child / ward received any immunisation in the last 2 years? No

Has your child / ward had any illness recently or does your child / ward have a long term medical No
condition?

Is your child / ward taking any medicine currently? No

Consent for Primary School Dental Programme

YES. I consent to my child / ward receiving dental treatment from the School Dental Service.
Did your child / ward have any previous dental treatment? No

Declaration
By submitting this document, I:

a) understand that the information provided will supersede all information previously submitted in hardcopy and / or
electronic forms; and
b) confirm that the information provided is true to the best of my knowledge.

Father's Name: LIN JUNXIONG ANDY

Father's NRIC/BC/FIN: S8400411A

Mobile No.: 81839223

Home No.: 66399905
Office No.:

Email Address: andylim84@gmail.com

Submit Date & Time: 23-12-2017 14:16:07

NOTE TO PARENTS / GUARDIANS:

For the safety and well being of your child / ward, it is very important to provide the Health Promotion Board (HPB) with the
LATEST information on your child's / ward's health status throughout his / her school life.
If you wish to change the status of consent for immunisation and school dental programme, or update your child's / ward's
medical information, please login to Child Consent Portal using SingPass.
If you do not wish your child / ward to be screened annually in school by the School Health Service staff, please write to:
Director, Youth Preventive Services Division
Health Promotion Board
3 Second Hospital Avenue, Singapore 168937

You may be contacted by HPB for medical appointments and health promotion programmes.