Health Check-up

PASTE YOUR
RECENT
PASSPORT
First Name: Middle Name: Last Name: SIZE
PHOTOGRAPH
Company’s Name: Sr. No.:
Employee Code : Department:
Designation:

Declaration
I declare that the undersaid information is true and correct to the best of my knowledge.
If any of this information is found to be false / incomplete / incorrect the company can
cancel my appointment or terminate my service contract. No legal implications
regarding the same will be borne by Bureau Veritas (India) Pvt Ltd or
Bureau Veritas Certification (India) Pvt Ltd.

Date:

Thumb Impression / Signature of the candidate

Personal History

1. Smoking: ______________ Quantity: day for-Years: _________

2. Alcohol: Quantity: day for- Years:

_________

3. Tobacco /Gutkha: 4.Any Other: 5. Bowel : Normal /

Regular:

6. Bladder; Normal / Regular:: 7. Diet: Veg. /Non Veg. 8. Tea /

Coffee:

9. Vasectomy:____________________________

10. Any Allergies (Including

Drugs):_________________________________________________

Health History

Any Present Complains: _____________________________________________________

H/O Hypertension/Diabetes Mellitus/Heart Disease/Epilepsy :

______________________

Any other significant past illness: ______________________________________________

Any Accidents in past: _______________________________________________________

Any Surgical Intervention:____________________________________________________

Any Allergies (Including Drugs):________________________________________________

Any ongoing medications:

Any Occupational Related Health Hazards (Previous/Present):

___________________________

General Examination
Physical Parameters :
Height : Weight :
Physical Deformities :
Conjunctiva : Pallor / Icterus :
Nail : Pallor / Icterus / Clubbing :
Edema : Pedal / Facial / Generalized :
Nodes / Glands / Thyroid :

Ears / Nose / Throat (ENT) External Examination

1. Ear Examination :

2. Tonsils :

3. Sinuses :

4. Throat:

CVS (Cardiovascular System)

1. JVP.: 2. Heart Rate : . 3. Rhythm :

4. B.P. : 5. Heart beat-location :

RS (Respiratory System)
1.Shape of Chest : 2. Chest Expansion Measurements:
3. RR : 4. Air Entry
5. Breath Sounds : 6. Added Sounds :

GIT (Gastro Intestinal System)

1. Bowel Sounds: 2. Tenderness :
3. Ascites : 4. Palpable Mass :
5. Organomegaly : 6. Any Other :

Certifying Physician
Se
al Qualifications
Reg. No.
 PRE-EMPLOYMENT EVALUATION

Date: ____________ R/No.: ______________

First Name: __________________ Middle Name _______________ Last Name______________________

Company’s Name: _______________________________________________________________________
Address: ______________________________________________________________________________
Tel No: _____________________________________ Email: ___________________________________

Declaration declare that the under said information is true and correct to the best of
PAST YOUR
my knowledge. RECENT
If any of this information is found to be false / incomplete / incorrect the company can PASSPORT
SIZE
cancel my appointment or terminate my service contract. No legal implications PHOTOGRAPH
Regarding the same will be borne by Bureau Veritas (India) Pvt Ltd or
Bureau Veritas Certification (India) Pvt Ltd.

Thumb Impression SafetyofPledge

Signature the candidate Amelio Personnel
From this day onwards, I solemnly affirm that I will rededicate myself to the cause of safety, health
and protection of environment and will do my best to observe rules, regulations and procedure
and develop attitudes and habits conducive for achieving these objectives.
I fully realize that accidents and diseases are a drain on my Organization and the National
economy and may lead to disablement, death, damage to health and property, social suffering
and general degradation of environment.
I will do everything possible for the prevention of accidents and occupational diseases and
protection of environment in the interest of self, my family, my organization, my workplace, my
community and the nation at large.

_________________________ _____________________
Left Hand Thumb Impression Candidate’s Signature

_____________ ______________ __________________________________

Place Date Certifying Occupational Health Physician
 CERTIFICATE OF FITNESS

1. Name of the Company : __________________________________________________________

2. Serial No. : ____________________________________________________

3. Name : ____________________________________________________

4. Sex : ____________________________________________________

5. Residence : ____________________________________________________

6. Date of Birth : ____________________________________________________

7. Physical Fitness : Height: ____________ Weight: _______________

Chest : Normal: ____________ Expanded: ____________

Eyesight : Left : _____________ Right: ________________

8. General Examination :

BP.: __________ CVS: ___________ RS: ___________ CNS: ________________

9. Others : ____________________________________________________

10. Advice : _____________________________________________________________________

11. Descriptive Marks : I hereby certify that I have personally examined Mr. __________________, who

is desirous of being employed in factory and that his/her age as nearly as can be ascertained from

my examination is _______________ years and that he/she is FIT for employment in factory as an

adult child his/her descriptive marks are : ____________________

12. Reason for

1. Refusal of certificate : ____________________________________________________

2. Certificate being revoked : _________________________________________________

__________________________ _______________ _____________________

Certifying Industrial Health
Left Hand Thumb Impression of Date Physician
Candidate