Professional Documents
Culture Documents
Name: ……………………………………………………………………
Address: ……………………………………………………………………
……………………………………………………………………
D M Y
Date of Birth: Gender: Male / Female
8. Does the weather, dust, pollen affects your chest, nose or skin? Yes No
b. Bronchitis Yes No
c. Pneumonia Yes No
14. Have you ever had kidney stone(s)/suffered from kidney disease? Yes No
……………………………………………………………………………………………….
18. Have you ever suffered from reduced hearing/degree of deafness? Yes No
19. Have you ever suffered from difficulty in distinguishing colours? Yes No
…………………………………………………………………………………………………………………….
21. Have you ever had muscle, bone or joint related problems such as backache,
knee pain etc? Yes No
………………………………………………………………………………………………….
………………………………………………………………………………………………….
22. Have you ever had any surgical operation on any part of your body? Yes No
23. Did either of your parents or first degree relatives suffer from any chronic disease like Hypertension, Diabetes
Mellitus, Epilepsy or Cancer etc?
Yes No
If Yes, please give details: …………………………………….…………………………………..
………………………………………………………………….……………………..………………
………………………………………………………………………………………………….…..…
24. Have you ever suffered from blood diseases such as sickle cell anemia? Yes No
………………………………………………………………………………………..………..………
25. Are you aware of any birth defect or hereditary condition that you have? Yes No
……………………………………………………………………………………………….……….…
26. Kindly write down your blood group if you know it.
………………………………………………………………………………………………………….
If Yes, How many cigarettes per day? (or) how many pan masala per day?
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
30. Kindly mention any medical problem that you have if it has not already been mentioned above?
……………………………………………………………………………………………………
………………………………………………………………………………………….…………
I declare that my answers to the questions in this Personal Statement are correct and true and that I
have not withheld any information. I also agree and understand the following:
- that I will have to undergo a medical examination should there be a need and requirement.
- that any omission or suppression of information about my health may lead to the immediate
termination of my appointment with Hindustan Group without notice / benefit, and I will be liable
to pay the costs of recruitment to Hindustan Group
- that the Hindustan Group is the sole authority to decide my fitness to work with them after the
medical examination and its decision will be final in this regard.