Skip to content
Contact Us
Download App
Locations
About Us
About Pinnacle Family Clinic
Our Founder & Medical Team
Our Locations
Our Services
One-stop healthcare services
Medical Services
Health Screening
Imaging
Telemedicine
Vaccinations
Pinnacle Family Clinic App
Healthier SG & other Government Scheme
Healthier SG
Government Schemes
Corporate
Corporate Program
Insurance Partners
Nanyang Polytechnic
Health Resources & Updates
Also Part of Pinnacle Medical Holdings
Pinnacle Medical Centre
Pinnacle Imaging Centre
About Us
About Pinnacle Family Clinic
Our Founder & Medical Team
Our Locations
Our Services
One-stop healthcare services
Medical Services
Health Screening
Imaging
Telemedicine
Vaccinations
Pinnacle Family Clinic App
Healthier SG & other Government Scheme
Healthier SG
Government Schemes
Corporate
Corporate Program
Insurance Partners
Nanyang Polytechnic
Health Resources & Updates
Also Part of Pinnacle Medical Holdings
Pinnacle Medical Centre
Pinnacle Imaging Centre
Stay protected! Get your FLU Vaccine at any Pinnacle Family Clinic. Click
Here
to book your appointment now.
×
Contact
Locations
About Us
About Pinnacle Family Clinic
Our Founder & Medical Team
Our Locations
Our Services
One-stop healthcare services
Medical Services
Health Screening
Imaging
Telemedicine
Vaccinations
Pinnacle Family Clinic App
Healthier SG & other Government Scheme
Healthier SG
Government Schemes
Corporate
Corporate Program
Insurance Partners
Nanyang Polytechnic
Health Resources & Updates
Also Part of Pinnacle Medical Holdings
Pinnacle Medical Centre
Pinnacle Imaging Centre
About Us
About Pinnacle Family Clinic
Our Founder & Medical Team
Our Locations
Our Services
One-stop healthcare services
Medical Services
Health Screening
Imaging
Telemedicine
Vaccinations
Pinnacle Family Clinic App
Healthier SG & other Government Scheme
Healthier SG
Government Schemes
Corporate
Corporate Program
Insurance Partners
Nanyang Polytechnic
Health Resources & Updates
Also Part of Pinnacle Medical Holdings
Pinnacle Medical Centre
Pinnacle Imaging Centre
Bringing Healthcare Closer to You
ACS(I) - Appointment Request Form
Registration is now closed.
Cardiac Risk Assessment Questionnaire
A. PARENT DETAILS
Name:
(Required)
Contact Number:
(Required)
Email:
(Required)
B. PERSONAL DETAILS OF STUDENT
Full Name:
(Required)
NRIC/FIN:
(Required)
Nationality
(Required)
Singapore
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Gender:
(Required)
Male
Female
Date of Birth:
(Required)
MM slash DD slash YYYY
Class:
(Required)
C. MEDICAL HISTORY
Does the student have any heart disease diagnosis?
(Required)
Yes
No
State the heart disease diagnosis.
(Required)
Does the student have any history of chest pain or angina?
(Required)
Yes
No
Describe the condition the student experiences.
(Required)
Does the student have any angioplasty/stenting/bypass history?
(Required)
Yes
No
Describe the condition the student experiences.
(Required)
Does the student have any history of heart valve problems?
(Required)
Yes
No
Describe the condition the student experiences.
(Required)
Does the student have any history of arrhythmia or palpitations?
(Required)
Yes
No
Describe the chest pain the student experiences.
(Required)
Does the student have any history of fainting episodes?
(Required)
Yes
No
State the last date of the last sleeping walking occurrence and its frequency.
(Required)
Does the student have any history of shortness of breath disproportionate to activity?
(Required)
Yes
No
Describe the condition the student experiences.
(Required)
D. RISK FACTORS
Does the student have high blood pressure?
(Required)
Yes
No
Is the student on medication? If yes, what medication is the student on?
(Required)
Does the student have diabetes mellitus?
(Required)
Yes
No
When was the student diagnosed and what medication is the student on?
(Required)
Does the student have high cholesterol?
(Required)
Yes
No
When was the student diagnosed, and what is the latest LDL cholesterol reading?
(Required)
Does the student have family history of heart attack/stroke/sudden cardiac death?
(Required)
Yes
No
Please provide further details on the family history.
(Required)
On the average, how many days does the student exercise per week in the last four weeks? (At least 30 minutes or more of medium physical activity such as brisk walking, stair climbing, etc.)
(Required)
Never
1-2 days per week
3-4 days per week
5-7 days per week
Please contact us at
connect@pinnaclefamilyclinic.com.sg
or call our
24/7 hotline at 6235 1852
, if you require any further information and/or assistance.
We look forward to serving you soon
About Us
About Pinnacle Family Clinic
Our Founder & Medical Team
Our Locations
Our Services
One-stop healthcare services
Medical Services
Health Screening
Imaging
Telemedicine
Vaccinations
Pinnacle Family Clinic App
Healthier SG & other Government Scheme
Healthier SG
Government Schemes
Corporate
Corporate Program
Insurance Partners
Nanyang Polytechnic
Health Resources & Updates
Also Part of Pinnacle Medical Holdings
Pinnacle Medical Centre
Pinnacle Imaging Centre
Locations
Contact Us