Professional Documents
Culture Documents
1. PERSONAL DETAILS :
Name: ..........................................................................................................................................................................
(Surname) (Other Names)
Address: .......................................................................................................................................................................
Birth Place: ………………………………………….Date of Birth: ………………………Religion: ……………………………
Intended Occupation: ……………………………………..Marital Status: ………………………Sex: ………………...…..
2. FAMILY HISTORY: Has anyone of your family suffered from Cancer, Diabetes,
Tuberculosis, Epilepsy, Mental or Nervous disease? ___________________
IF LIVING IF DEAD
FATHER
MOTHER
BROTHER (NO.)
SISTER (NO.)
HUSBAND/WIFE
CHILDREN (NO.)
3. PERSONAL HISTORY :
Are you in good health and capable of full work ……………………………………………………………………………………
Types of Previous Occupation? …………………………………………………………………………………………………
Have you ever suffered from an occupational disease or injury?
Have you ever been discharged or rejected on medical grounds?
Date of last Vaccination………………………………………………………………………………………………………………
Have you ever suffered from any of the following (Answer Yes or No. if yes, give details)
Rheumatic Fever: Yes/No ………………………Any other illnesses: Yes/No. ………………………………….................
Heart trouble: Yes/No ……………………………………………..Jaundice: 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………………………….........… Venereal Disease: Yes/No…………………………………..........
Malaria : Yes/No…………………………………...........……Dermatitis or any skin disease : Yes/No……………..…….
Typhoid fever: Yes/No………………………………...........Any allergy or Yes/No……....................……………………..
Sinusitis: Yes/No…………………………………………............Ear trouble Yes/No…...............……..……....................
Operation or injuries: Yes/No…………..................…….. Menstrual History L.M.P. ………………..................…..
Do you have any physical handicap: Yes/No……………………………………………………….....................................
4. DECLARATION:
I declare that the above statements are true and complete to the best of my knowledge and belief and I agree that the results 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 statements if proved wrong the company may have unwillingly engaged my services and I shall therefore have no claim
against the company. If for these reasons I am discharged from its service.
Date: ………………………… Signature of Prospective Employee: …………………................
5. RESULT OF PHYSICAL EXAMINATION :
1. GeneralAppearance………………………………………………… Skin………………………………...............................................
2 .Throat………………………….Tonsils…………………Thyroid…………………………...Glands……………………….......................
3. Ears……………..…...........…Hearing E.G. Whisper 2 Meter………........…………………..Nose ………………..........…......
4. Teeth & Gums………............…………………………......………………..Tongue…………………..........………………..…................
5. Vision Distant: R.E.………………......…………L.E……………......……..Corrected R.E…………...…......…..L.E. …………...........
(provide the exact values)
SL Clinic City State Clinic Address Clinic pin Clinic Email Clinic Phone
7-1-621/109(61/3RT), Sanjeev
2 S.R. Nagar Hyderabad Telangana 500038 srnagar@apolloclinic.com (040) 2370 2237 - 9;
Reddy Nagar
50–81–1/2, Plot 5,
Vizag, Dwaraka Andhra (0891) 258 5511 - 2,
8 Vishakapatnam Sheethammapeta, 530016 vizag@apolloclinic.com
Nagar Pradesh 254 8818
Visakhapatnam
hc.alwarpet@apollospectra.
Apollo Day Surgery, No 12, CP
DAY CARE com; (044) 2467 2200,
25 Chennai Tamil Nadu Ramasamy Road, Alwarpet,
Alwarpet pragya.pandey@apollospec 2498 8865/66/67
Chennai - 600018
tra.com
Apollo Medical
Centre,No-30,FBlock, annanagar@apolloclinic.co (044) 2620 6666,
26 Anna Nagar Chennai Tamil Nadu
2nd Avenue, Annanagar East, m 26224505
Chennai - 600102
011-25918222/
The Apollo Clinic,C-70, Major Sudesh 25918333
Kumar Marg, Opp. Madhav Park,Near Mobile No: +91
2 Rajouri Garden Delhi Delhi rajourigarden@theapolloclinic.com
Main Market, Rajouri Garden, New Delhi 9711203302,
- 110027 9811061009
Fax: 011-25918444
The Apollo Clinic, Mann Complex, Anand adajan@theapolloclinic.com 0261 – 279 0202 /
3 Adajan, Surat Surat Gujarat
Mahal Road, Adajan, Surat – 395 009 apolloclinicsurat@gmail.com 279 5031
Ph.: (0497)-
kannur@theapolloclinic.com 2768041/42/43, Fax:
The Apollo Clinic, CW-35/2935, City
prasadpaickat@gmail.com (0497) - 2768 046.
5 Kannur Kannur Kerala Centre, Fort, Road.Kannur 670 001
premkumarmenon@rediffmail.com Phone: 040 - 2311
Kerala.
fawazabdulla@hotmail.com 8001 /8002 /
Fax: 040 – 2311 8003.
doonapollo@rocketmail.com;dehra
The Apollo Clinic, Melody Cottage,
23 Dehradun Dehradun Uttaranchal dunapollo@gmail.com;dehradun@t 91-9219044012
8/4-1, Ballupur Road, Dehradun
heapolloclinic.com