NUS Dentistry UNDERGRADUATE PREADMISSION Y1 2026

NUS Dentistry UNDERGRADUATE PREADMISSION Risk Assessment Form 2026

The Occupational and Diving Medicine Centre

Entrusted with the Health of ALL @ Work

Faculty of Dentistry has a medical surveillance programme for all staff and students to protect the health of the individual. This questionnaire will only be used by NUS Occupational Health Clinic. The questionnaire is secured and meets the US HIPAA (Health Insurance Portability & Accountability Act) requirements for medical information. A password protected copy will be sent to you. Please print a copy and bring it along with you to the clinic.

Do attach any relevant medical documents at end of questionnaire or bring them along during the medical consultation.
Name (according to NRIC/FIN/ID)*
MaleFemaleOther
DentistryOther
Preadmission to Y1 DentistryPreadmission to Graduate Dental SchoolExit for Final Year Dental StudentsOther
Email*
example@example.com
NRIC/FIN *
Date of Birth*
SingaporeanOther
Home Address*
Tel No (Handphone)*
Tel No (Home)*
Please list any known allergies?*
In case of emergency, person to contact*
Relationship *
Person's Contact No*
Person's Email Address*
NoYesIf Ýes' please provide details
NoYesIf Yes, please provide details (diagnosis, treatment, date, duration)

Personal Medical History: Have you suffered from or undergone any of the following:*

Rows	No	Yes	Details
Allergies
Acute/Chronic Respiratory Disorders
Blood Disorders
Gastro-intestinal Disorders
Heart Disorders
Injuries or Deformities
Kidney/Urinary Disorders
Muscular/Joint Disorders (eg scoliosis)
Skin Disorders
Surgical Procedures
Eye or Visual problems
Allergies/Allergic rhinitis/ Sinusitis
Environmental or latex allergies
Deafness or ringing noises in ear
Asthma/Shortness of breath
Fainting or Fits/Epilepsy
Paralysis, muscle weakness or numbness
Diabetes mellitus
Chronic viral infetions - Hepatitis B, C or HIV
Autoimmune disease eg lupus
Long term steroids or other medication
Cancer
In Hospital for any reason
Any other conditions (eg GSPD deficiency, menstrual disorders)

PES Grading in NS (if applicable)
RightLeftOther
What vaccinations have you taken? Verify based on Health booklet, Health Hub/other documents
NoYes. Date:
NoYes. Date:
NoYes. Date:
NoYes. Date:
NoYes. Type and Dates:
I do not smokeI do not drink/ only a social drinkerI exercise regularly at least twice a week.Describe exercise if any:
On average, how many hours do you listen to music/drama using earpiece?*
I hereby certify that the answers given by me to the above listed questions are correct and true. I understand that NUS at its discretion can choose not to bear costs of any future illness, treatment or investigation that may arise, should there be false or incomplete declaration of the above. I have no objection to the release of my medical reports from the hospital(s) or doctor(s) concerned, if necessary.I consent for the relevant medical information to be conveyed to NUS including Supervisor, Faculty of Dentistry or other departments in NUS
Note: A soft copy of questionnaire will be sent to you via email together with password. Please print and bring along with you to clinic. You can make an appointment via link: https://odmc.as.me/under FOD PRE-ADMISSION
Signature of Student*

Clear
Date*

DayMonthYear
File Upload

Cancelof
TO BE FILLED BY DOCTOR
Consultation Notes
DENTISTRY MEDICAL CERTIFICATE
Height (m)
Weight (kg)

NormalAbnormal.Other
Blood Pressure (mmHg)
RegularIrregularBeats per Min
Grip Strength. Right hand (kg)
Grip Strength. Left hand (kg)

Normal hearingAbnormal hearingNo significant deterioration compared to previous audiogramDeterioration compared to previous audiogram - severity:
NegativePositive
Hepatitis B Titres
NegativePositive
NegativePositive
ImmuneNot immune. Advise vaccination.
ImmuneNot immune. Advise vaccination.
TDAP vaccine on:

DayMonthYear
Date
Negative for Hepatitis B, Hepatitis C and HIVImmune to Hepatitis B and completed 3 doses of Hepatitis B vaccinationsImmune to Measles, Mumps, RubellaImmune for VaricellaSatisfactory AudiogramSatisfactory Grip StrengthSatisfactory Chest XrayImmune to Tetanus, Diptheria, PertussisWeak Grip Strength of Dominant handNot immune to Hepatitis BNot immune to Varicella
Advised Hepatitis B vaccinationAdvised Hepatitis B booster to promote longer lasting immunity and prevent antibodies from waningAdvised Varicella vaccinationAdvised Measles, Mumps, Rubella vacinationAdvised Tetanus, Diptheria, Pertussis vaccinationAdvised strengthening exercisesAdvised stretching and regular exercise to reduce musculoskeletal symptoms during clinical/lab workTo monitor for any aggravation of eczema (due to lab chemicals)To monitor for any aggravation of asthma (due to lab chemicals)To reduce music via ear piecesTo have a repeat hearing test in Year 2To use ear defenders such as ear plugs or ear muffs during noisy lab workOther
Physician Remarks (if applicable):
FITUNFIT
Date of Examination

DayMonthYear
Date
Physician's Name & Stamp

DR GREGORY CHAN CHUNG TSING. PPA(G), PP

MBBS, MMED Occup Med, GDip Geriatric Med, GDip FP Derm

Senior Specialist Physician, Occupational Medicine

MCR: M06367C
Signature

Clear
Clinic Stamp and Address:

THE OCCUPATIONAL AND DIVING MEDICINE CENTRE

20 Lower Kent Ridge Road University Health Centre Singapore 119080
Should be Empty:

Rows	Far	Near	Comments
Right Uncorrected
Left Uncorrected
Right corrected
Left corrected

Rows	Normal	Abnormal	Details
Eyes (other than myopia)
Cardiovascular
Respiratory
Gastrointestinal
Neurological
Psychiatric
Muscular/Skeletal
Other Conditions

Rows	NEGATIVE	ABNORMAL
Sugar
Protein
pH
RBCs (uL)
WBCs (uL)
ECs (uL)

Rows	0.5 KHZ	1 KHZ	2 KHZ	3 KHZ	4 KHZ	6 KHZ	8 KHZ
RIGHT AC
LEFT AC
RIGHT BC
LEFT BC

Rows	Negative	Positive	Value
Albumin
Sugar
Blood

Rows	Normal	Abnormal	Remarks	Date of Xray
CXR

TO BE FILLED BY DOCTOR

DENTISTRY MEDICAL CERTIFICATE