HITS/DHRD/HDF/005

HEALTH DECLARATION BY CANDIDATE

Name (in full)

Date of Birth

Gender Male / Female

Blood Group

Physical disability, if any

Kindly answer all the following questions:

Do you have any health issues, if yes, please Yes No

1
give details

(a) Do you take any medication Yes No

Have you ever suffered from difficulty in
2 Yes No
distinguishing colours
3 Have you ever had skin problems. Yes No

4 Have you ever suffered from heart disease? Yes No

5 Have you ever had?

(a) Surgery

(b) Bronchitis

(c) Pneumonia

(d) Pulmonary Tuberculosis

(e) Bronchial Asthma

(f) Allergies

(g) Fits

(h) Jaundice
Have you ever had kidney stone(s)/suffered
10 Yes No
from kidney disease?
Have you ever suffered from blood diseases
11 Yes No
such as sickle cell anemia
Have you ever had muscle, bone or joint
12 Yes No
related problems such as backache, knee

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 pain, etc.,
13 Have you ever had any ENT problems Yes No

14 Have you ever suffered any chronic illness

(a) Acid peptic disease

(b) Hypertension

(c) Diabetes

(d) Psychological illness

(e) Others, Please specify

Are you aware of any birth defect or
15 hereditary condition that you have? If so,
Please specify.
16 Do you smoke / use tobacco Yes No
If Yes, How many cigarettes per day? (or)
17
how many pan masala per day
18 Do you have any health issue due to smoking Yes No

19 Do you consume alcohol Yes No

 Medical fitness certificate to be attached (validity for one year)

I declare that my statements 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.

- 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

- 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.

Name & Signature of Candidate: _________________________________ Date: _______

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