RELIANCE LIFE SCIENCES PRIVATE LIMITED

PRE-EMPLOYMENT MEDICAL EXAMINATION

[Prospective employee should fill in Section 1 to 4. The Examining Medical Officer will fill in Section % & 6
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 ? __________

AGE

IF LIVING
HEALTH (GOOD,
BAD, FAIR)

IF DEAD
AGE AT
DEATH

CAUSE OF
DEATH

FATHER
MOTHER
BROTHERS (NO.)
SISTERES (NO.)
HUSBAND / WIFE
CHILDREN NO.
2.

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. _____________
Veneral 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. _____________________________

3.

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 is proved wrong the company may have unwittingly 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 ________________________________

RESULTS OF PHYSICAL EXAMINATION :

1.

General Appearance _______________________ Skin _______________

2.

Throat __________ Tonsils ___________ Thyroid ________ Glands _______

3.

Ears ______________ Hearing E.G. Whisper, 20 ft. _________ Nose ______

4.

Teeth & Gums _______________________ Tongue ____________________

5.

Vision Distant : R.E. _6/_ L.E. _6/_ Corrected R.E. ___6/____ L.E. ___6/____
Near : R.E. N/
L.E. N/
Corrected R.E.
N
L.E.
N/
Eye Disease _________________________ Colour Vision __________________

6.

Height __________________________ Chest Exp. _____________________ Insp. ____________________

Weight __________________________ Girth at Navel __________________________________________

7.

Hearth-Sounds ______________________ Murmurs ____________________________________________

Arteries ____________________________ Blood Pressure _______________________________________
Pulse-Rate ___________________________ Character _________________________________________

8
9.

Lungs ________________________________________________________________________________
Abdomen _________________________ Liver ________________ Spleen ________________________

10. Urinary and Genital Organs _______________________________________________________________

Venereal Disease _______________________________________________________________________
11. Special Conditions : Flat feet ______________________________ Varicose Veins _________________
Hernia _________________________________ Deformities _________________________________
Scars ________________________________________________________________________________
Identification Marks __________________________________________________________________
12. Nervous System ______________________________ Pupilary Reaction _______________________
Plantars _______________________ Knee Jerks ______________ Rhomberg _________________
Urine : Sp. Gr. _____________ Reaction ____________ Albumin _________ Sugar _____________
Microscopic (If required) _____________________________________________________________
Blood Hemoglobin __________________ Blood Sugar ____________ Blood Group ___________
13. Chest X-Ray / Screening ___________________________________________________________
14.

E.C.G. : ______________________________________________________________________

14. Other Investigations if any __________________________________________________________

6.

COMMENTS AND RECOMMENDATIONS:

Date :

Examined By