The Medical Declaration Form serves as a crucial document in Malaysian healthcare documentation, designed to collect and verify essential medical information from individuals. This form is typically required in various contexts, including medical treatments, insurance applications, employment procedures, and travel requirements. The document complies with the Medical Act 1971 and Personal Data Protection Act 2010, ensuring proper collection and handling of sensitive medical information. It includes comprehensive sections for personal medical history, current health status, and necessary declarations, with provisions for both self-declaration and professional medical verification. The form is structured to protect both the declaring individual and the receiving organization, incorporating necessary legal safeguards and data protection measures as required under Malaysian law.
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1. Personal Information: Basic details of the declarant including full name, IC/passport number, date of birth, gender, and contact information
2. Medical History: Declaration of current and past medical conditions, surgeries, and treatments
3. Current Medications: List of all current medications, supplements, and treatments being undertaken
4. Family Medical History: Relevant family medical history for hereditary conditions
5. Lifestyle Declaration: Information about smoking, alcohol consumption, and other lifestyle factors affecting health
6. Declaration of Truth: Legal statement confirming all provided information is true and accurate
7. Consent for Information Use: Authorization for the collection, use, and disclosure of provided medical information
8. Signature Section: Space for declarant's signature, date, and witness details
1. Emergency Contact Information: Optional section for providing emergency contact details - recommended for forms used in ongoing medical relationships
2. Insurance Information: Details of medical insurance coverage - include when form is being used for insurance or billing purposes
3. COVID-19 Declaration: Specific declarations related to COVID-19 exposure and vaccination - relevant during pandemic conditions
4. Pregnancy Status: Declaration of pregnancy status - include when relevant to medical treatment or assessment
5. Third Party Declaration: For cases where the declaration is made by a guardian or authorized representative on behalf of the patient
1. List of Medical Conditions: Detailed checklist of common medical conditions for reference
2. Medication List Template: Structured template for listing current medications and dosages
3. Privacy Notice: Detailed information about how medical data will be collected, used, and protected
4. Terms and Conditions: Full terms and conditions regarding the use and implications of the medical declaration
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