Medical Examination Checklist

HMER Digital Form — Kenneth Tan Medical Clinic

Fitness to Drive Assessment

Licence Group Assessment

Select the appropriate SMA guideline group for this assessment. Medical practitioners must refer to the SMA 'Fitness to Drive' guideline.

Group 1

Driving Licence only
(Class 2 and 3)

Group 2

Class 4 & 5 Driving Licence
Vocational Licence (Taxi/Bus)

Examinee Details

Patient identification for the medical examination record.

Full Name

NRIC / FIN

Date of Examination

Age

Examinee Declaration

The examinee must sign below to endorse this declaration before the medical examination proceeds.

I, (name) , NRIC/FIN (NRIC/FIN) , hereby declare that:

1. The information I have provided in this medical examination checklist, including my recent occurrences and medical history, is true and accurate to the best of my knowledge.
2. I have not withheld any relevant medical information that may affect the assessment of my fitness to drive.
3. I understand that providing false or misleading information may result in the revocation of my driving/vocational licence.
4. I consent to this medical examination being conducted for the purpose of assessing my fitness to hold a driving and/or vocational licence.

Examinee Signature

Recent Occurrences

Check if the examinee has the below occurrences in the past six (6) months.

#	Description	Check
1	Currently consulting any medical practitioner for pre-existing or newly diagnosed medical condition
2	Currently taking any medication for pre-existing or newly diagnosed medical condition
3	Been warded or discharged from hospital recently
4	Been receiving rehabilitative treatment recently (for stroke patients)
5	Any relevant medical problems or injuries not mentioned above
6	Have you ever attended DARP or DARS before

Medical History

Check if the examinee has the below medical history.

#	Description	Check
	Cardiac / Pulmonary Systems
1	Palpitations or breathlessness
2	Asthma / bronchitis / COPD
3	High blood pressure
4	Heart attack / disease
5	Chest pain on exertion or at night
	Neuro / Musculo-skeletal System
6	Psychiatric illness
7	Severe headaches or migraine
8	Stroke / TIA
9	Epilepsy, seizures or fits of any kind / faints
10	Head injury or concussion
11	Muscle disease or weakness
12	Arthritis / joint disease / numbness in hands & fingers
	Vision / Hearing
13	Eye trouble of any kind (e.g. cataracts, glaucoma, strabismus)
14	Difficulty seeing in the dark
15	Deafness
	Endocrine System
16	Diabetes
17	Thyroid Disease
18	Surgical Operations
19	Any relevant medical problems or injuries not mentioned above (S/N 1–18)

Notes (if any items checked)

General Medical Examination

Clinical assessment findings by the examining medical practitioner.

#	Description	Assessment
1	General Condition
2	Cardio-vascular System S1 S2: Murmurs: BP: / mmHg Heart Rate: bpm
3	Finger-nose co-ordination Test
4	Any evidence of abnormality of the Lungs
5	Any evidence of abnormality of the Abdomen
6	Any evidence of abnormality of the Neuro-muscular System
7	Any evidence of abnormality of the Nervous System
8	Any evidence of psychiatric disorder
9	Any defect in hearing
10	Any deformities and/or physical disabilities observed
11	Any abnormality or limitations in range of movement of the joints (e.g. Straight Leg Raise)
12	Any limitation in strength of upper limbs and lower limbs (power)
13	Any evidence of being addicted to the excessive use of alcohol or drug?
14	Does the applicant show any sign of cognitive impairment? (If yes, Abbreviated Mental Test must be completed)

Examination Notes

Tests of Vision

For vocational licence holders, acuity should be at least 6/12 in each eye, with or without optical aids.

#	Test	Assessment
1	Colour Perception — ability to recognise accurately the colours red, green & amber
2	Visual Acuity (Snellen Eye Chart) Right Eye (RE) Left Eye (LE) With glasses/optical aids
3	Near Vision Right Eye (RE) Left Eye (LE) With glasses/optical aids
4	Binocular vision (required for vocational licence holders only)

Abbreviated Mental Test (AMT)

Ask the examinee to remember: "37 Bukit Timah Road." Each correct answer scores 1 point. Score < 7 suggests cognitive impairment.

#	Question	Score
1	What is the present year? (Western calendar)
2	What time is it now? (within 1 hour)
3	What is your age? (for Chinese, +1 year acceptable)
4	What is your birth date? (Western year, month & day)
5	Where are we now? (Clinic or hospital is acceptable)
6	What is your home address? (complete address except postal code)
7	Who is Singapore's current Prime Minister?
8	Show picture of a profession and ask what his/her job is
9	Count backwards from 20 to 1
10	Please recall the memory phrase ("37 Bukit Timah Road")

AMT Score: — /10

For Vocational Licence Applicants/Holders Only

If the examinee is referred to a specialist, the examinee must obtain the specialist's report and present it to the same medical practitioner for review.

#	Description	Yes / No
1	Tuberculosis (Requires TB Certificate from TBCU or MOH)
2	Heart Surgery (Requires memo from Cardiologist if pacemaker implanted)
3	Stroke (Requires DARP report and Neurologist memo)
4	Mental illness (Anxiety, Depression, Schizophrenia, Bipolar) (Requires psychiatrist/physician memo)
5	Amputee (Requires DARP report)
6	Hearing problems (Requires Audiogram and hearing specialist memo)
7	End Stage Renal Failure on Haemodialysis (Requires attending physician memo)
8	Cancer undergoing Chemotherapy or Radiotherapy

Vocational Assessment Notes

X-ray Examination

Only applicable to new applicants or if instructed by LTA. Check that the chest X-ray report corresponds to the examinee.

There is no radiological evidence of chest lesion The applicant is suffering from TB Not applicable

Overall Assessment

Final determination of fitness to drive/hold licence.

Fitness Determination

Comments / Conditions

Copy to Plato

Preview the output and copy to clipboard for pasting into your clinic management system.

Click "Generate Preview" to see the output...

Submit to LTA

Once you have completed the medical examination and copied the results to Plato, submit the official HMER form to LTA via the link below.

Submit HMER to LTA →

go.gov.sg/hmer

Medical Disclaimer: This digital form is a clinic workflow tool and does not replace the official HMER form. Always refer to the SMA 'Fitness to Drive' guideline when certifying fitness.