Personal Information
Email address
*
Preferred Date / Tarikh
*
-
Day
-
Month
Year
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Patient's Name (Follow exact name in NRIC or exact name in Passport)
*
NRIC / Passport No:
*
Date of Birth
*
-
Month
-
Day
Year
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Age
*
Telephone No. / Handphone No.
*
Gender
*
Female
Male
Marital Status
*
Single
Married
Divorced
Widowed
Race
*
Religion
*
Nationality
*
Malaysian
Singaporean
Indonesian
Other
Address / Alamat
*
Postcode
*
City
*
State
*
Country
*
Payment Mode
*
Self Pay
Corporate
Other
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Next of Kin's Name (Emergency Contact Person Name)
*
NRIC / Passport No:
*
Telephone No. / Handphone No.
*
Gender
*
Female
Male
Race
Religion
Nationality
Malaysian
Singaporean
Indonesian
Other
Address / Alamat
*
Postcode
*
City
*
Relationship
*
State
*
Country
*
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Your Child History
Your child medical/ surgical and vaccination history are important for our paediatrician to review and assess your child. Please assist us to complete the following questionnaires to provide us the accurate information.
Birth weight (kg)
*
Was your child a premature baby?
*
Yes
No
If your answer is Yes, please tell us how many week?
*
Was there any medical problems during first month of life?
*
Yes
No
If Yes. Please specify
*
Is your child currently having any health issues?
*
Yes
No
If Yes. Please specify
Has your child been hospitalised before?
*
Yes
No
If Yes. Please specify
Do you have any concerns about your child’s growth and development?
*
Yes
No
If Yes. Please specify
Is your child currently taking any regular medications?
*
Yes
No
If Yes. Please specify
Does your child have any drug or food allergies?
*
Yes
No
If Yes. Please specify
Does your child have any feeding difficulties?
*
Yes
No
If Yes. Please specify
Are there any major medical conditions among family members?
*
Yes
No
If Yes. Please specify
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VACCINATION REVIEW
Newborn - BCG
*
Yes
No
If yes, please state the date
Newborn - Hep B
*
Yes
No
If yes, please state the date
1-2 months - Hep B
*
Yes
No
If yes, please state the date
2 months - DTaP IPV Hib
*
Yes
No
If yes, please state the date
3 - 4 months - DTaP IPV Hib
*
Yes
No
If yes, please state the date
5 - 6 months - Hep B
*
Yes
No
If yes, please state the date
9 - 12 months - MMR
*
Yes
No
If yes, please state the date
12 - 15 months - MMR
*
Yes
No
If yes, please state the date
18 - 24 months - DTaP IPV Hib
*
Yes
No
If yes, please state the date
18 - 24 months - DTaP IPV Hib
*
Yes
No
If yes, please state the date
5 - 7 years - MMR
*
Yes
No
If yes, please state the date
6 - 7 years - DT/DTaP IPV
*
Yes
No
If yes, please state the date
6 - 7 years - BCG ( if no scar )
*
Yes
No
If yes, please state the date
9 - 13 years - HPV (1st)
*
Yes
No
If yes, please state the date
9 - 13 years - HPV (2nd)
*
Yes
No
If yes, please state the date
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Additional Vaccines
Rotavirus - 1st
Yes
No
If yes, please state the date
Rotavirus - 2nd
Yes
No
If yes, please state the date
Rotavirus - 3rd
Yes
No
If yes, please state the date
Pneumococcal – 1st
Yes
No
If yes, please state the date
Pneumococcal – 2nd
Yes
No
If yes, please state the date
Pneumococcal – 3rd
Yes
No
If yes, please state the date
Pneumococcal – 4th
Yes
No
If yes, please state the date
Chicken Pox - 1st
Yes
No
If yes, please state the date
Chicken Pox - 2nd
Yes
No
If yes, please state the date
Influenza - 1st
Yes
No
If yes, please state the date
Influenza - 2nd
Yes
No
If yes, please state the date
Influenza - 3rd
Yes
No
If yes, please state the date
Influenza - 4th
Yes
No
If yes, please state the date
Japanese Encephalitis B - 1st
Yes
No
If yes, please state the date
Japanese Encephalitis B - 2nd
Yes
No
If yes, please state the date
Hep A - 1st
Yes
No
If yes, please state the date
Hep A - 2nd
Yes
No
If yes, please state the date
Meningococcus - 1st
Yes
No
If yes, please state the date
Meningococcus - 2nd
Yes
No
If yes, please state the date
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I declare all the information provided to be true and correct. I agree to the collection, use and disclosure of my child personal information to Hospital Lam Wah Ee ( HLWE ).HLWE seeks to use the Personal Data only for the purposes of legitimate interests.
*
Yes
Submit
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