Document: HRP

Issue Date:
HR Policy Procedures Effective from
Version: Ver 6
Guidelines on Pre-Employment Medical Assessment

Annexure-2 PASTE YOUR

Self-Declaration RECENT
PASSPORT SIZE
PHOTOGRAPH

1 PERSONAL DETAILS:

(First Name) (Middle Name) (Surname/ Last Name)

Gender (male / female): Age (Years):

Post Applied for:

Height (cm): Weight (Kg): Blood Pressure:

2 PREVIOUS EMPLOYMENT: Yes / No (If yes specify)

SN Company Name Nature of Work Duration

(in years)

3 PERSONAL HABITS:
Yes No
Smoking
Tobacco Chewing
Alcohol

Page 1 of 4
 Document: HRP
Issue Date:
HR Policy Procedures Effective from
Version: Ver 6
Guidelines on Pre-Employment Medical Assessment

Any Other: If yes specify

4 MEDICAL HISTORY:
i) DISABILITY: Yes / No
(If yes specify the details and disability % if certified)

………………………………………………………………………………………………………………………
…………………………….

………………………………………………………………………………………………………………………
…………………………….

ii) VISION:
a) Acuity of Vision:
Are you using Spectacles / Glasses: Yes / No (If yes specify power below)

Right Eye:

Left Eye:

b) Colour Vision:
Color Blindness: Yes / No (If yes pls mention details below)

iii) PAST HISTORY:

a) Any illness / injury / accidents / hospitalization after your last Annual Health
Checkup: Yes / No (If yes specify)

b) Any illness / injury / accidents in past: Yes / No (If yes specify)

Page 2 of 4
 Document: HRP
Issue Date:
HR Policy Procedures Effective from
Version: Ver 6
Guidelines on Pre-Employment Medical Assessment

c) Any job-related disease and / or injury: Yes / No (If yes specify)

d) Terminated or Rejected on medical grounds: Yes / No (If yes specify)

iv) RECENT HISTORY:

On medication for following (Answer Yes or No.)

High Blood Pressure

Hearing Problem
(Hypertension)
High Blood Sugar Fainting, Fits, Epilepsy,
(Diabetes) Dizziness
Heart Disease Any mental disorder
Kidney Disease Hepatitis B
Tuberculosis Any liver disorder
Chronic Lung Disease Cancer
Ear Disease Stroke or Brain problem

Any Other:

v) IMMUNIZATIONS:
Yes No

Page 3 of 4
 Document: HRP
Issue Date:
HR Policy Procedures Effective from
Version: Ver 6
Guidelines on Pre-Employment Medical Assessment

COVID 1st Dose

COVID 2nd Dose

5 I declare that the above statements are true and complete to the best of my knowledge and
belief. In case this information is found to be false by the company, then the company reserves
the right to terminate my services without giving any notice. 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 in case I am declared medically unfit due to any reason, I shall not be entitled for
the employment in the company. However, the decision taken by recruitment committee about
my medical fitness will be final and binding to me.

…………………………………………………………
(Signature of Candidate)

Date: ………………………………………………

Page 4 of 4
 h6me:
Age / Cender D6te:

Annexure-3
Pre-Employment Medic6l Assessment
(AII det6iIs given beIow wiII be fiIIed by ex6mine physici6n 9 tre6ted 6s confidenti6I)
(PIe6se √ M6rk Where AppIic6bIe)

1 Person6l H6bits:
i) Smoking

ii) Tob6cco chewing

iii) AIcohoI

iv) Any other

2 Medic6l History:
i) Any Dis6bility: Yes / ho If yes specify with dis6biIity %
ii) Person6l History:

iii) Known c6se of or p6st history of

iv) Immuniz6tion: Yes ho

Tet6nus Toxoid
Hep6titis B
Others

F6mily History:
H6s 6nyone of p6rents suffered from
Hypertension Di6betes
He6rt Dise6se TubercuIosis
C6ncer EpiIepsy
Any other Dise6se

P6ge 1 of 4
 h6me:
Age / Cender D6te:

3 Physic6l Ex6min6tion:
i) BuiId: Poor / Aver6ge / Strong Skin:
ii) Thro6t: TonsiIs: Thyroid: Lymph nodes:
iii) Teeth 9 Cums: Tongue:
iv) Height cms Weight kg BMI

v) Identific6tion m6rks:

1 Vision (To be checFed by eye speci6list):

Gener6l Eye ex6min6tion:
Rt Lt CoIour Vision (PIs √ M6rk AppIic6bIe)
Visu6I Acquity Dist6nce horm6I CoIour vision
he6r Tot6I coIour deficiency
Corrected Vision Dist6nce P6rti6I CoIour Deficiency
he6r
Spheric6I If p6rti6I − pI. mention
Power of Iens CyIindric6I
Axis

Yes ho

Squint
hyst6gmus
hight BIindness
Any other eye dise6se

If yes pI. give det6iIs

Sign6ture 9 Se6I of Ophth6ImoIogist

P6ge 2 of 4
 h6me:
Age / Cender D6te:

ħ He6ring:

Extern6I Ex6min6tion: Rt Lt
Rinne’s Test: Weber’s Test:
Convers6tion6I He6ring/ Whispering:
Audiometry (Comment):

dB Right E6r dB Left E6r _

6 C6rdio-v6scul6r System:

PuIse−R6te /min BIood Pressure mm hg

Sys Di6
He6rt Sounds Murmur Present Absent Det6iIs if present

Ch6r6cter: ReguI6r / IrreguI6r

7 Respir6tory System:
Sh6pe of Chest: Bre6th Sounds:
_________________________________________
8 Abdomen:
Liver: SpIeen: Any Abdomin6I Lump:
9 Genito Urin6ry System:
Herni6: HydroceIe/V6ricoceIe:
1O Venere6l Dise6se:

11 Speci6l Conditions: FI6t feet V6ricose Veins

12 ervous System:
PupiII6ry Re6ction: PI6nter RefIex:

Knee Jerk RefIex: Rhomberg Sign: +ve −ve

13 Investig6tions:

i) Urine: Sp. Cr. Re6ction AIbumin Sug6r

Microscopic:

BIood: H6emogIobin g% HbA1c BI. Cr. +ve -ve

ii) Chest X−r6y:

iii) E.C.C:

iv) USC WhoIe Abdomen:

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 h6me:
Age / Cender D6te:

v) 2D Echo/TMT:

vi) PFT: FVC FEV1 FEV1/FVC % _ PEFR

vii) Any other Investig6tions / cIinic6I finding:

14 COMME TS A D RECOMME DATIO S:

(PIs √ M6rk AppIic6bIe)

Fit Unfit

Rem6rks:

Det6ils of Ex6mining Physici6n:

h6me: _
Registr6tion ho.:
Address: _

Cont6ct ho.: _ _
Sign6ture with Se6I of Ex6mining Physici6n

For office use only:

D6te of receipt of origin6I documents: PEM ho.:
MDMS ho:

Medic6IIy Fit Temp. Unfit Unfit

Speci6I Rem6rks:

P6ge 4 of 4