Pre-Employment Medical Form
Pre-Employment Medical Form
Pre-Employment Medical Form
Intended Occupation: (Desk Job / Field Job). If Field Job, Nature of Work – _______________
2. FAMILY HISTORY: Has anyone of your family suffered from Cancer, Diabetes, Hypertension
Tuberculosis, Epilepsy, Mental or Nervous disease? _____
IF LIVING IF DEAD
AGE HEALTH (GOOD,BAD, FAIR) AGE AT DEATH CAUSE OF DEATH
FATHER
MOTHER
BROTHERS (NO.)
SISTERS (NO.)
HUSBAND/WIFE
CHILDREN (NO.)
3. 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 illness: Yes/No._____
Heart 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.___
Do you have any physical handicap: Yes/No
4. 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 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 its service.
8. Lungs ____________________________________
Scars____________________________