Pre-Employment Medical Questionnaire

Human Resources Department

Medical information will be used to evaluate the potential impact on visa and work permit applications and to ensure
Mediclinic complies with related health and safety requirements prior to entry into the workplace.
All information will be treated with the necessary respect and confidentiality it deserves.

Name

Designation
Place of Work
(Hospital/Clinic/Office)

MEDICAL HISTORY Yes No

Do you have any medical condition or currently use medication that may impact your ability to work?

If you answered yes

please provide
details
Tuberculosis Yes No

Have you ever been diagnosed with Tuberculosis?

If you answered yes

please provide
details
Other Conditions
Yes No
To the best of your knowledge, do you or did you have the following medical conditions?
HIV

Hepatitis B

Hepatitis C

MRSA or other communicable diseases

Chickenpox Yes No

Have you ever had Chickenpox?

If you answered yes

please provide
details

Yes No N/A
Pregnancy Status

If yes, please indicate Expected Date of Delivery

Immunization History
Have you had any of the following immunization? Yes No Date

Chickenpox

Flu Vaccine

Hepatitis B

Declaration: I declare that the answers to the questions in this form are correct to the best of my knowledge. I further declare
that I am not suffering from any disease, the presence of which I have not revealed. I fully understand that any breach of
this declaration could lead of to the cancellation of my application.

Signature of
Date
Candidate

MCME.HR.5.1