Do you have any of the following health problems? Yes No Remark
If Yes, specify in remark coloum 1 High / low blood pressure P 2 Diabetes Mellitus (Blood Sugar Problem) P 3 Heart related problems - Chest pain, Heart Attack, Congenital conditions, valvular heart disease etc. P 4 Respiratory related problems - Asthma/Shortness of breath/Chronic cough etc. P 5 Nervous system related problems - Convulsion/Fits/Paralysis/Polio etc. P 6 Liver/Gall Bladder related problems like jaundice /Hepatitis/Gall stones etc. P 7 Digestive system related problems - Peptic ulcer/bloody vomiting or stool/irregular bowel habits etc. P 8 Kidney related problems - Renal stones/Blood in urine etc P 9 Blood related problems - Anemia/Low platelet count/Sickle cell anemia/Thalessemia etc. P 10 Any endocrine related disorder like thyroid conditions etc P 11 Musculoskeletal disorders - Backache/Limb deformity/disc problem/joints problem etc. P 12 Eye related problems - Refractive errors/colour blindness/squint/cataract etc. P 13 Do you wear any contact lenses? P 14 Ear related problems - Ear discharge/hearing loss/tinnitus etc. P 15 Skin related problems - Rashes/psoriasis/scars etc. P 16 Are you suffering from any communicable diseases? - Tuberculosis/HIV/Hepatitis B /Leprosy etc. P 17 Mental Health related problem P 18 Any Allergy - Drug/Food/Other P 19 Vertigo / Giddiness P 20 Phobia (Fear of hight or closed places/darkness) P 21 Ankle swelling/Hernia / Hydrocele/Abdominal swelling etc P 22 Any history of hospitalisation in past? P 23 Any history of past surgeries? P 24 Consumption/Habit - Drug/Alcohol/Tobbaco/Smoking? P 25 Any history of long term medications? OR currently taking any medication? P 26 Any history of occupational injuries/illness in past? P 27 Any past history of cyanosis? (Bluish discolouration of tongue/lips/nails) P 28 Family History of Diabetes/Hypertension/Heart Attack/Mental disorder/ Asthma/cancer P Last Menstrual Period ____________ NA 29 For Female Any gynaecological disorder? NA 30 Any present complaints? NA
Additional Remark
I hereby declare that, to the best of my knowledge and belief, the particulars given above and the declaration made therein are true. For non-routine work only : I hereby declare that I will not work in chemical process areas in violation of the company policy.
