PRE-EMPLOYMENT MEDICAL EXAMINATION Please affix

(For Executive employees)

(Prospective employee should fill in Section 1 to 4 your
The Examining Medical Officer will fill in Section 5 to 6 photograph
All details given below will be treated as confidential)

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
AGE HEALTH (GOOD, BAD, FAIR) AGE AT DEATH CAUSE OF DEATH
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. 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. General Appearance…………………………………………………….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. ………………....
(Please provide the exact values)

Near: R.E.…………..……….L.E…………………..Corrected R.E………….…………….L.E. …………………………………….

(Please provide the exact values)

Eye Disease……………………………………………….... Color Vision……………………………..……………….………

6. Height (cm)…………………..….Chest. Exp. (cm)……………………….………Insp (cm)…………………………….……...
Weight (kg)……………………………………………..……Girth at Navel (cm)………………………………….……….….…….
7. Heart Sounds……………………………………………………………..Murmurs…………………………………………….………....
Arteries…………………………………………………………………..Blood Pressure (Sys/dia)……………………….….…...…
(Please provide the exact values)

Pulse-Rate…………………………………………………………………..Character………………………………………………..…….
8. Lungs………………………………………………………………………………………………………………………………………………….
9. Abdomen………………………………..……Liver…………………………………………………..Spleen………………………..……
10. Urinary and Genital Organs………………………………………………………………………..………………………………………
Venereal Disease…………………………………………………………………………………...………………………………………….
11. Special Conditions: Flat feet …………….……………………..Varicose Veins……………………………………………………
Hernia………………………………………………………………………Deformities………………………………………………………
Scars…………………………………………………………………………………………………………………………………………………..
12. Nervous System………………………………………………………Pupillary Reaction……………………………….…………….
Plantars……………………….………………Knee Jerks ………………………………..Romberg…………………………………….
Urine: Sp. Gr. ………………Reaction …………………………………….…Albumin ………………..Sugar………….………….
Microscopic (If required)…………………………………………………………………………………………………………………….
Blood Haemoglobin (g%)………………Blood Sugar (FBS/RBS)……..……….Blood Group…………………….
(Please provide the exact values) (Please provide the exact values)
13. Chest X-ray/Screening…………………………………………………………………………………………………………………………
14. E.C.G: ……………………………………………………………………………………………..………………………………………………..
15. Other Investigations, if any: ………………..………………………………………………………………………………………………
16. Medically Fit: Yes/ No ______

6. COMMENTS AND RECOMMENDATIONS :

Date: ………………………….. Examined By: ……………………………