PRE-EMPLOYMENT MEDICAL EXAMINATION

(For Executive employees)

(Prospective employee should fill in Section 1 to 4
All details given below will be treated as confidential)

1. PERSONAL DETAILS
Name
SUMTTCHAKRABORTY
(Surname) (Other Name)
Address 109/9, D.C DEy ROAD KOLKATA 00015
Birth Place KOLKATA Date of Birth /19/1992 Religion 9TNDU
Intended Occupation 6ERUICEMarital Status Sex MALE
2. FAMILY HISTORY Has anyone of your family suffered from Cancer, Diabetes,
Tuberculosis, Epilepsy, Mental or Nervous disease?

IF LIVING IF DEAD
AGE AGE AT DEATH CAUSE OF DEATH
HEALTH (GOOD, BAD, FAIR)
FATHER NORMAL
MOTHER 65 | G00D
BROTHER (NO.)
SISTER(NO |99 00D
HUSBAND/WIFE
CHILDREN (NO.)
3. PERSONAL STORY
Are you in good health and capable of full work VES
Types of Previous Occupation? SALE5 MARKETINQ
Have you ever suffered from an occupational disease or injury?
Have you ever been discharged or rejected on medical grounds?
Date of last Vaccination 19/06/2091 C1ST DOSE)
Have you ever suffered from any of the following (Answer Yes or No. if yes, give details)

Rheumatic Fever: NO Any other illnesses: NO

Heart trouble: NO Jaundice: NO
Stomach or other digestive
disorder:
NO Diabetes NO
Asthma: N O Pleurisy: NO Fits, fainting or dizziness
Nervous/Mental disease of any
Pulm T.B.: NO Chr. Bronchitis NO kind: NO
Kidney disease: NO Venereal Disease:
NO
Malaria: NO Dermatitis or any skin disease: NO
Typhoid fever: NO Any allergy NO
Sinusitis: NO Ear trouble: NO
Menstrual History L.M.P. NO
Operation or InjuriesS NO
Do you have any physical handicap NO
4.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 1shall therefore have no claim against the company. If for these reasons I am discharged from its
service.

Signature of Prospective uatkangkosly

Date: 11-May-20 Employee: