SELF DECLARATION FORM - MEDICAL FITNESS

PERSONAL DETAILS
POSITION
NAME GENDER APPLIED FOR BLOODGROUP
HEARING
AGE JOINING DATE EMP ID (LEFT EAR) NORMAL/ABNORMAL
WITH /
NORMAL / WITHOUT HEARING
WEIGHT HEIGHT VISION ABNORMAL GLASSES (RIGHT EAR) NORMAL/ABNORMAL

GENERAL INFORMATION (Pls tick YES / NO, wherever applicable)

Sr. No. Reponses YES NO

Have you had any serious illness? If YES, give details below
1

2 Have you ever had a transfusion?

Have you ever been hospitalized or been under medical care for longer than 5 days? If YES, give reasons
3 below.

Do you suffer from any allergies? If YES, give details of the type of allergy below.
4

Have you ever undergone any surgery. If YES, give details of the surgery below
5

6 Have you ever been seriously injured in a motor vehicle accident or had a serious physical injury of any
kind?
7
Have you had any head concussions or injuries?

Do you consume tobacco in any form? If YES, please give details of the frequency of usage.
8

Do you consume alcohol in any form? If YES, please give details of the frequency of usage
9

Do you consume drugs in any form? If YES, please give details below
10

Are you under regular medication for any particular ailment or condition? If YES, please specify below
11

Have you been diagnosed with Hypertension / Diabetes / Heart Trouble / Stroke? If YES, please specify
below
12

Has either parent / sister / brother / child / grandparent ever had a Stroke / Tuberculosis / Diabetes / Heart
Trouble / High blood pressure OR any other hereditary health history (Pls tick & give details below
13 wherever applicable)

14 How much time have you lost from work / study due to your health during the past? (Pls tick wherever
applicable) One month / Three months / Six months / One Year / 5 Years
Most recent immunizations: (Pl. tick wherever applicable)
15
Hepatitis B / Flu Vaccine / Pneumovax / Tetanus

I hereby declare that the information provided in this document is true to the best of my knowledge and if
proved wrong, the organization has complete authority to terminate my services

Signature, Seal and Registeration No.

Signature of the employee of the Registered Medical Practitioner

NF/HR-TAG/005 Fmt. Rev. Date August 25,2008

Have you worked in WNS earlier – Yes/No ?

Please share Employee ID if worked earlier -