EMPLOYMENT HEALTH DECLARATION

FULL NAME (AS PER IC) MARITAL STATUS

IC NUMBER (NEW) SEX / AGE HEIGHT (CM) / WEIGHT (KG)

A Personal History / Family History Yes No Please provide details for “YES”
answers (Diagnosis, dates, etc)
a) Have you ever had or been treated for any serious
illness or surgical operation in the past 5 years?

b) Have you or any of your family members ever suffered

from a nervous or mental disorder, fits or epilepsy,
hypertension, diabetes, cancer, heart diseases, stroke,
tuberculosis, asthma, hepatitis, or any hereditary
diseases?

c) Have you any personal allergies or had any adverse

reaction to any form of medication?

d) Are you on any form of long-term/daily medication at

present?

e) Are you on follow-up with any Specialist?

f) Have you ever been hospitalized in the past 2 years?

g) Have you had any Chest X-rays in the past 2 years?

h) Do you have visual impairments e.g. short/long sighted,

color blind?

B Female Candidates Only

i) Have you ever had any disease of the breast/breast

lump(s)/breast cysts?

ii) Have you ever had any disease of the female organs eg.
ovarian cysts, fibroids, endometriosis?

iii) Are you pregnant now? If yes, how many months?

I hereby declare that to the best of my knowledge the representations above are correct and true. I understand that
any misrepresentation or omission of facts shall be considered sufficient cause for denying employment or
termination of my employment.

_______________________ ___________________________
Date Signature of Candidate