MEDICAL EXAMINATION

1. PERSONAL DETAILS:

Name:_______________________ Surname__________________________ Age____________

Address:_______________________________________________________________________

Martial Status________________ Sex_________

2. FAMILY HISTORY

| |AGE |HEALTH(GOOD, BAD, FAIR) |AGE AT DEATH |IF DEAD |
|Father | | | | |
|Mother | | | | |
|Brother (NO) | | | | |
|Sisters (NO) | | | | |
|Husband/Wife | | | | |
|Children (NO) | | | | |

3. PERSONAL HISTORY:(Self Declaration)
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 discharge or rejected on medicals 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 Jaundices: Yes/No
Stomach or other digestive disorder: Yes/No Diabetes: Yes/No
Asthma: Yes/No, Pleurisy: Yes/No Fits fainting or dizziness: Yes/No
Plum TB: Yes/No, Chest Bronchitis: Yes/No Nervous mental disease of any kinds: Yes/No
Kidney Disease: Yes/No Veneral Disease: Yes/No
Malaria: Yes/No Dermatitis or any skin disease: Yes/No
Thyroid fever: Yes/No Any allergy or: Yes/No
Sinusitis: Yes/No Ear allergy or: 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 statement are true and complete to the best of my knowledge and behalf 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 statement if proved wrong the company may have unwitting engaged my services and I shall therefore have no claim against the company, if for these reason I m discharged from its services.

Date: _______________ Signature of prospective Employee 5. RESULT OF PHYSICAL EXAMINATION (by qualified medical practitioner, no investigation test to be performed) 1. General Appearance:___________________________________ Skin:_______________________________ 2. Throat_________________________ Tonsils_____________________ Glands________________________ 3. Ears_______________________ Hearing E.G. Wishper.20 ft_______________________ Nose___________ 4. Teeth & Gums__________________________________ Tongue ___________________________________ 5. Vision Distant: R.E.__________ L.E._____________ Corrected R.E._____________ L.E._______________ Near: R.E.__________________ L.E._____________ Corrected R.E._____________ L.E._______________ Eye Disease ____________________________________ Color Vision ______________________________ 6. Height ____________________ Chest Exp. ___________________ Insp.____________________________ Weight _________________ Girth of abdomen _________________________________________________ Heart Sound _______________________________________ Murmurs______________________________ Arteries___________________________________________ Blood Pressure__________________________ Pulse Rate_________________________________________ Character______________________________ 7. Lungs___________________________________________________________________________________ 8. Abdomen________________________ Liver_________________________ Spleen____________________ 9. Urinary & Genital Organ___________________________________________________________________ Veneral Diasese___________________________________________________________________________ 10. Special Conditions: Flat Feet_________________________________ Vericose Vein___________________ Hernia__________________________________ Deformities______________________________________ Scars __________________________________________________________________________________ Identification Marks_______________________________________________________________________ 11. Nervous system_________________________________ Pupillary Reaction___________________________ Plantars_____________________ Knee Jerks_______________________ Rhomberg___________________

6. INVESTIGATIONS REQUIRED ( From SRL-Religare Lab only those mentioned below) 1. BloodSugar(f)_________________________________________________________________________ 2. SCreatinine___________________________________________________________________________ 3. HIV,HbSAg____________________________________________________________________________ 4. CBC,Lipidprofile________________________________________________________________________ 5. Other Investigations_____________________________________________________________________ 6. Blood Group___________________________________________________________________________

7. COMMENTS AND RECOMMENDATIONS:

Signature, Registration No. with seal of qualified allopathic medical practitioner.