Reliance Industries Limited Pre-Employment Medical Examination PASTE YOUR (Prospective employee should fill in Section 1 to 4 RECENT ‘The Examining Medical Officer will fill in Section 5to6 | PASSPORT SIZE All details given below will be treated as confidential ERORCREEE: Please V Mark Where Applicable) 4 PERSONAL DETAILS: First Name Middle Name Surname ‘Address: (iy) 0 gee eel Cue aap aha Contact Details: Mobile No. : Resi. No Birth Place: Birth Date Religion (@a/mm/yyyy) For post applied Marital Status: Married / Unmarried Sex M/F 2 EAMILY HISTORY Has anyone of your family suffered from Diabetes Hypertension Heart Disease Arthritis [Tuberculosis |Asthma \Cancer Epilepsy Mental or Nervous Disorder |Any other disease TF LIVING IF DEAD ‘AGE HEALTH |AGEATDEATH [CAUSE OF DEATH (Good, Bad, Fair) Father [Mother [Brother (No) Sister (No.) /Husband/ Wife (Children (No.) 3 PERSONAL HISTORY: Yes No ‘Are you in good health and capable of full work Have you ever suffered from an occupational disease or injury ? Have you ever been discharged or rejected on medical grounds ? ‘Types of Previous Occupation (PI. describe in brief about company, nature of work, duration in years) Page 1 of4‘Name Of Candidate Have you taken any vaccination? Yes / No (Ifyes complete / partial) Have you ever suffered from any of the following (Answer Yes or No. if yes, give details) YN: YN Heart disease Hypertension Diabetes \Chronic abdominal /digestive disorder Kidney disease |Hepatitis-B JAsthma |Chronic lung disease (e.g, bronchitis, pleurisy, pneumonia ete.) [Tuberculosis [Malaria / Typhoid fever in last 6 months Dermatitis or any skin disease |Venereal or Sexually Transmitted Disease Epilepsy, Fits, fainting or dizziness INervous/Mental disease of any kind Any allergy |Any chronic ear or hearing problem (e.g. sinusitis, rhinitis, otitis etc.) |Any major operation or injury |Any other illnesses [Do you have any physical handicap Details of any of above if "Yes") (For female candidates only) Are you pregnant at present? [Y JN] Date of LM.P. 4 Tdeclare that the above statements are true and complete to the best of my knowledge and belief and agree that the results of this medical examination in general terms may be revealed to the company if required. I also fully understand that in case I am declared medically unfit due to any reason, 1 shall not be entitled for the employment in the company. However, The decision taken by the company’s doctor/s about my medical fitness will be final and binding to me. [Date (4d/mm/yyyy) [Signature of Prospective Employee 5 RESULT OF PHYSICAL EXAMINATION: doctor: jon 1t0 1 General Appearance 2 Throat ‘Tonsils Thyroid Glands 3. Ears “Hearing (e.g. Whisper at 2 meter) Nose 4 Teeth & Gums Tongue 5 Height Jems Weight lkg Girth at Navel Jems Chest: Expiration Jems Inspiration Jems Page 2 of 410 12 3 16 Name Of Candidate Vision (Lo be checked by eve specialist) Colour Vision (Pls V Mark Applicable) ‘ion ae hese a Normal Colour vision Near ‘Total Colour Deficiency With glass Distance Partial Colour Deficiency Near If partial - pl. mention for which colour Poweroflens Spherical Cylindrical Axis Yes_ No Squint ‘Any other eye disease ifyes pl. give details, Heart Sounds Murmur [ Present | Absent ]Detais if present Arteries Blood Pressure mm hg Se Dia Pulse-Rate /enin Character Lames Abdomen Liver Spleen Urinary and Genital Organs Venereal Disease Special Conditions : Flat feet ‘Varicose Veins Hernia Deformities| Sears Identification marks: 1 2 Nervous System Pupilary Reaction Planters Knee Jerks Rhomberg [ve [ve Urine : Sp. Gr. Reaction Albumin Sugar Microscopic (If required) Blood Haemoglobin 1g% Blood Sugar IFBS/RBS BL.Gr. wwe [ve Chest X-ray tos ase ECG ‘Any other Investigations / Page 3.of4Name Of Candidate : COMMENTS AND RECOMMENDATIONS : (Pls V Mark Applicable) (please refer standards for recruitment) Fit [Unit Remarks: [Date (dd/mm/yyyy) Address of Examining Doctor ‘Signature with Seal of Examining Doctor Date of receipt of original documents: Medically [Fit [ Temp. Unfit | Unfit Special Remarks: Verification done by medical offi Signature Name Date: Fitness certificate issued [Yes [No] Fitness certificate sent on (date) Page 4 of 41 2 7__ Pregnancy will render the female candidate temporarily unfit, until confinement. ‘STANDARDS FOR RECRUITMENT ‘The prospective employee shold not have any physical deformities due to birth defects, illness like polio or past injuries. Candidate should not have defects in vision like partial or total colour blindness and high myopia ‘The maximum power of lense permissible for correction of vision in case of myopia should be -4D. Ifhigh myopia, he/she should undergo LASIK surgery and produce certificate from eye-surgeon that 4) Post LASIK corrected vision is less than -4D. 2) Post LASIK fundoscopy examination should reveal normal retinal findings. One eyed candidates will be declared unfit. (Standards for acceptable vision for various categories is enclosed as per Annexure - 1). Candidate's sense of hearing should be normal. Candidate should not be grossly under / over weight. (Refer the body weight chart for as per Annexure IL). Candidate should not have any communicable disease. Candidate should not be suffering from any other major diseases like hypertension, epilepsy diabetes, kidney disease, heart disease, diseases of liver and central nervous system. LIST OF TESTS TO BE CONDUCTED General physical examination, by a Registered Medical Practitioner having minimum M.B.B.S. qualification. Eye examination by a qualified ophthalmologist. CB.C. and blood sugar examination. Blood group Routine urine examination. Urine examination for pregnancy test (in case of female candidates) X-Ray Chest. ECG,(1) For Employees a) Below 35 ym5. working in plant, of age 6/9 6/9 security Sire or or Services 6/6 6/2 [by a5 yrs. of Bos | Sa08 asia thors 6/32 6/32 or or 6/9 68 (IT) Others |a) Below 35 yrs. 6/9 6/12 ‘$n.0.6 ‘$n.0.6 (except lof age 6/38. 6/18. plant, security & fire [b) g5yrs oF 6/12 6/24 Tno8 | Sn08 services age and above faq 6/24 Personnel )Annexure -II-A Reliance Group of Industries ‘Medical Department Guidelines for Body Weight for Men WEIGHT (Kes) Height (Murs) [Roceptable Average] Acceptable Wt. Rat is a 0 = 6a, 1.60 6, 52-65, 1.62 8.6. 53 - 66 1 16 1.66 60.6 69 1.68 Z 1% 6 65.0 “z 66. 176 68.0. 178 eisaaeleR PNIg 70 72 2B 76 78 ‘80. a 8; ES 87 38 0. 26) 2 758 78 81.0) Annexure - Il-B Reliance Group of Industries ‘Medical Department Guidelines for Body Weight for Women WEIGHT (Kes) Height (sttrs) _[eseptable Average] Acceptable Wt. Range Overweight x 60, 42 = 55, 148 465 42 rr 10 1.52. 8 158 1.60) 1.62 1.64 1.66 1.68 2 472 NIB |SIS|S|L1213 218 [| ia|zis|aia|z|a|2\3 | 176 4