PHOTOGRAPH
TO BE AFFIXED
Reliance Industries Limited
Retail Business
PRE-EMPLOYMENT MEDICAL EXAMINATION
(Prospective employee should fill in Section 1 to 4. The Examining Medical Officer will fill in Section 5&6 All details given
below will be treated as confidential)
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1. PERSONAL DETAILS :
Name: ……………………………………………………………………………………………………………………
(Surname) (Other Name)
Address: ………………………………………………………………………………………………………………………………
Birth Place: ………………….. Date of Birth: ………………………….. Religion: ……………………………………….
Intended Occupation: ………………………. Marital Status: ……………………… Sex: …………….………………….
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2. FAMILY HISTORY: Has anyone of your family suffered from Cancer,
Diabetes, Tuberculosis, Epilepsy, Mental or Nervous disease?
IF LIVING
Age HEALTH (GOOD, BAD, FAIR) AGE AT CAUSE OF DEATH
DEATH
FATHER
MOTHER
BROTHER (NO.)
SISTER (NO.)
HUSBAND / WIFE
CHILDREN (NO.)
3. PERSONAL HISTROY
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 ground?
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 illness: Yes / No. ________________________
Hear 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.: _________________
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: Yes / No. __________________
Do you have any physical handicap: Yes / No. ___________________________________________________________
Are you Pregnant : Yes / No/ Not Aware
(Chest X Ray should be avoided in case of pregnancy)
I declare that the above statements are true and complete to the best of my knowledge and belief and I agree that the
4.
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 if proved wrong the company may have unwillingly engaged my services
and I shall therefore have no claim against the company, if for these reasons I am discharged from it’s service.
Date: ……………………….. SIGNATURE OF PROSPECTIVE EMPLOYEE: …………………………
5. RESULTS OF PHYSICAL EXAMINATION
1. General Appearance __________________________________ Skin __________________________________
2. Throat ______________________ Tonsils ___________ Thyroid ____________ Glands __________________
3. Ears _________________ Hearing E.G. Whisper 20 . _______________ 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 _______________________________ Colour Vision ____________________________________
6. Height ________________________________ Chest Exp. _____________________ Insp. ________________
Weight _______________________________ Girth at Navel _______________________________________
7. Hearth sounds ________________________ Murmurs ____________________________________________
Arteries _____________________________ Blood Pressure ________________________________________
Pulse – Rate __________________________Character ____________________________________________
8. Lungs ____________________________________________________________________________________
9. Abdomen ____________________________ Liver __________________ Spleen _______________________
10. Urinary and Genital Organs ___________________________________________________________________
Venereal Disease ____________________________________________________________________________
11. Special Conditions : flat feet __________________________ Varicose Venis ___________________________
Hernia ________________________________ Deformities __________________________________________
Scars _____________________________________________________________________________________
Identification Marks _________________________________________________________________________
12. Nervous System _________________________________ Pupilary Reaction ____________________________
Plantars _________________________ Knee Jerks __________________ Rhomberg ____________________
Urine : Sp. Gr. ____________ Reaction ____________ Albumin ____________________ Sugar ____________
Microscopic (if required) ______________________________________________________________________
Blood Haemoglobin ___________________ Blood Sugar ______________ Blood Group __________________
13. Chest X-Ray / Screening _______________________________________________________________________
14. E.C.G. : _____________________________________________________________________________________
15. Other Investigations, if any _____________________________________________________________________
16. Medically Fit: Yes / No __________ Comments/Suggestions: _____________________________
DATE: …………………… EXAMINED BY: ………………………………
(Registration Stamp of Doctor)
