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    Medical Form & Document Checklist

    Uploaded by

    rjadhav0075
    The document is a self-declaration medical fitness form for an employee applying for a position. It requests personal details like name, gender, age, and contact information. It asks the applicant to provide health-related information such as weight, height, vision, hearing, history of illnesses, surgeries, hospitalizations, allergies, and use of tobacco, alcohol, or drugs. It also inquires about regular medications, conditions like hypertension, diabetes, or hereditary health issues. The applicant must declare that the information provided is true and the organization can terminate employment if any information is found to be incorrect.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Medical Form & Document Checklist

    Uploaded by

    rjadhav0075
    20 views2 pages
    The document is a self-declaration medical fitness form for an employee applying for a position. It requests personal details like name, gender, age, and contact information. It asks the applicant to provide health-related information such as weight, height, vision, hearing, history of illnesses, surgeries, hospitalizations, allergies, and use of tobacco, alcohol, or drugs. It also inquires about regular medications, conditions like hypertension, diabetes, or hereditary health issues. The applicant must declare that the information provided is true and the organization can terminate employment if any information is found to be incorrect.

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    Medical

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    The document is a self-declaration medical fitness form for an employee applying for a position. It requests personal details like name, gender, age, and contact information. It asks the applicant to provide health-related information such as weight, height, vision, hearing, history of illnesses, surgeries, hospitalizations, allergies, and use of tobacco, alcohol, or drugs. It also inquires about regular medications, conditions like hypertension, diabetes, or hereditary health issues. The applicant must declare that the information provided is true and the organization can terminate employment if any information is found to be incorrect.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    20 views2 pages

    Medical Form & Document Checklist

    Uploaded by

    rjadhav0075
    The document is a self-declaration medical fitness form for an employee applying for a position. It requests personal details like name, gender, age, and contact information. It asks the applicant to provide health-related information such as weight, height, vision, hearing, history of illnesses, surgeries, hospitalizations, allergies, and use of tobacco, alcohol, or drugs. It also inquires about regular medications, conditions like hypertension, diabetes, or hereditary health issues. The applicant must declare that the information provided is true and the organization can terminate employment if any information is found to be incorrect.

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    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 -

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