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Jindal Steel and Power Limited

PRE- EMPLOYEMENT MEDICAL EXAMINATION

1)

PERSONAL DETAILS:
Name ____________________________________________________________
(Surname)
(Other Name)
Address: __________________________________________________________
Birth Place: _________________ Date Birth : _________________
Intended Occupation ________________ Marital Status ___________ Sex ____

2)

FAMILY HISTORY: Has anyone of your family suffered from Cancer, Diabetes,
TB, Epilepsy, Mental or Nervous Disease? _____________
If Yes then give details: ____________________________
IF LIVING
Age

Father
Mother
Brother (No)
Sister (No)
Husband / Wife
Children (No)

IF DEAD
Health (Good, Bad, Fair).

Age at
Death

Cause of Death

3)

PERSONAL HISTORY

i. Are you in good health and capable of full work _______________________________


ii. Types of Previous Occupation _____________________________________________
iii. Have you ever suffered from an occupational disease or injury ?
iv. Have you ever been discharged or rejected or rejected on medical grounds ?
v. Date of Last Vaccination: ________________________________________
Have you suffered from any of the following : (Answer Yesor No. If Yes, give Details)
Rheumatic Fever: Yes / No _____________ Any other Illness: Yes /
No_______________________________
Heart Trouble: Yes / No________________ Jaundices: Yes /
No_____________________________________
Stomach or other digestive disorder: Yes / No ________ Diabetes: Yes /
No____________________________
Asthma: Yes/No______Pleurisy: Yes/No_________ Fits Fainting or dizziness: Yes/No
___________________
Pulm T.B: Yes / No_____ Chr.Bronchitis: Yes/No_____ Nervous/ mental disease of any kind:
Yes/No________
Kidney Disease: Yes / No _____________________ Veneral Disease: Yes /
No__________________________
Malaria: Yes / No ____________________________ Dermatis or any skin disease:
Yes/No________________
Typhoid Fever: Yes / No______________________ Any Allergy: Yes /
No______________________________
Sinusitis: Yes / No___________________________ Ear Trouble: Yes /
No______________________________
Operation of Injuries: Yes / No________________ Menstrual history
L.M.P_____________________________
Do you have any physical handicap: Yes /
No______________________________________________________

I hereby declare that the above statement are true and complete to the best of my
knowledge and belief and I agree that the result of this medical examination in general
terms may be revealed to the company if required. I also fully understand that if any of
the said statement if proved wrong the company may have unwittingly engaged my
service and I shall therefore have no claim against the company, if for this reasons Im
discharged from its services.

Date _______________________

Signature of prospective Employee

4) RESULTS OF PHYSICAL EXAMINATION:


1. General Appearance _____________________________________ Skin _____________
2. Throat ______________Tonsils ____________ Thyroid ____________Glands________
3. Ears _______________ Hearing E.G Whisper, 20ft ___________ Nose _____________
4. Teeth & Gums ___________________________ Tongue _________________________
5. Vision Distant : R. E. ________ L.E. __________ Corrected R.E. ______ L.E. ________
a. Near : R. E. ________ L.E. __________ Corrected R.E. ______ L.E. _______
Eye Disease __________________________________ Color Vision ___________
6. Height _______________________ Chest Exp. ________________ Insp. ___________
Arteries ________________________________ Girth at Navel ___________________
7. Heart Sounds __________________________ Murmurs _________________________
8. Lungs _________________________________________________________________
9. Abdomen ___________________ Liver __________________ Spleen ______________
10. Urinary and Genital Organs ________________________________________________
Venereal Disease ________________________________________________________
11. Special Condition: Flat Feet ______________________Varicose Veins _____________
Hernia ___________________________ Deformities ___________________________

Scars _________________________________________________________________
12. Nervous System _______________________ Papillary reaction ___________________
Planters _____________________ Knee jerks ____________ Romberg ____________
Urine: Sp. Gr.____________ Reaction ___________ Albumin _______ Sugar ________
Microscopic (if required) __________________________________________________
13. Chest X Ray / Screening ___________________________________________________
14. E.C.G. _________________________________________________________________
15. Other Investigations .if any ________________________________________________

6) COMMENTS AND RECOMMERDATIONS:

Annexure - 1
List of Tests to be conducted
1. General physical examination,
2. X-Ray chest PA View
3. Urine Routine and microscopy
4. Urea Serum
5. Cholesterol Serum
6. SGOT
7. SGPT
8. Hb (Hemoglobin)
9. ESR
10. Blood Grouping (ABO & Rh)
11. ECG
12. HIV test
13. Eye check up and Medical Officer Consultation

Guidelines:

An authorization letter from your company is required to avail of health check


up.
All Health Check Ups are conducted by prior appointments only.
Approximate time for the completion of the entire package is around 2 Hrs.
Avoid alcohol and heavy meals from 24 hrs prior to your appointment
Avoid a late night before your appointment
You are advised not to take any medication a day prior to the checkup.
You may take usual medications before the blood test except those for diabetes.
Drugs for diabetes should be brought with you and taken with breakfast.
You are requested to bring samples of urine (fewer quantity / 2 spoon full) when
you come for check up. You can get sterilized containers from clinic a day prior
to check up or you can purchase it from any pharmacy shop nearby.
Wear loose clothing, No jewelry (Necklaces / Chains) and easily removable
footwear.
Please bring previous medical reports (if any) and medical accessories like
glasses, hearing aid if you have any when you come for Health Check Up.
Please be informed that certain tests like x-rays are not to be done if you are
likely to be pregnant.
Inform the clinic in advance if you want any additional Investigations or
consultations to be done so that we can schedule your appointments for the
same.
We can provide additional Tests / Investigations / Procedures / Consultations at
request or if required however these will be billed separately in addition to the
package payment.