Pre-Employment Medical Examination

PASTE YO UR
(For Leader/ Manager Job Level) RECENT PASSPRT
SIZE PHO TO GRAPH
(Prospectiv e employ ee should fill in Section 1 to 4 (Attested by the
The Examining Medical Officer w ill fill in Section 5 to 6 Examiner)

All details given below w ill be treated as confidential

Please √ Mark Where Applicable)
1 PERSONAL DET AILS :

First Name Middle Name Surname

________________________________________________________________________

Address: ____________________________________________________________

____________________________________________________________________

____________________________________________________________________

City __________________________________________
Pin:_______________

Birth Place: _____________________

Birth Date _________________ Religion _________________
(dd/mm/y y y
y)
For post applied _________________________
Marital Status: Married / Unmarried Sex M / F

2 FAMILY HIST ORY

Has any one of y our family suffered from

Diabetes Hy pertension Heart Disease Arthritis

Tuberculosis Asthma Cancer Epilepsy

Mental or Nerv ous Disorder Any other disease

IF LIV ING IF DEAD

AGE HEALTH AGE AT DEATH CAUSE OF DEATH

(Good, Bad, Fair)
Father

Mother

Brother (No.)

Sister (No.)

Husband/Wife

Children (No.)

3 PERSONAL HIST ORY : Y es No

Are y ou in good health and capable of full work

Hav e y ou ev er suffered from an occupational disease or injury ?

Hav e y ou ev er been discharged or rejected on medical grounds ?

Ty pes of Prev ious Occupation (Pl. describe in brief about company , nature of work, duration in y ears)
 Name of Candidate: _________________________________________

Hav e y ou taken any v accination? Y es / No (If y es complete / partial) _____________________

Have y ou ever suffered from any of t he following (Answer Yes or No. if y es, give det ails)

Y N Y N

Heart disease Hy pertension

Diabetes Chronic abdominal /digestiv e disorder

Kidney disease Hepatitis-B

Asthma Chronic lung disease (e.g. bronchitis,

pleurisy , pneumonia etc.)
Tuberculosis Malaria / Ty phoid fev er in last 6 months

Dermatitis or any skin disease V enereal or Sex ually Transmitted Disease

Epilepsy , Fits, fainting or dizziness Nerv ous/Mental disease of any kind

Any allergy Any chronic ear or hearing problem

(e.g. sinusitis, rhinitis, otitis etc.)
Any major operation or injury Any other illnesses

Do y ou hav e any phy sical handicap

Details of any of abov e if "Y es")

(For female candidates only ) Are y ou pregnant at present?

Y N Date of L.M.P. ___________

4 I declare that the abov e statements are true and complete to the best of my knowledge and
belief and I agree that the results of this medical ex amination in general terms may be
rev ealed 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 employ ment in the company .
Howev er, The decision taken by the company 's doctor/s about my medical fitness will be final
and binding to me.
Date (dd/mm/y y y y ) Signature of Prospectiv e Employ ee

5 RESULT OF PHY SICAL EXAMINAT ION :

(Ex amining doctor should ensure that candidate has filled up section 1 to 4)

1 General Appearance ___________________Skin ___________________

2 Throat _______________Tonsils _________ Thy roid _________ Glands ____________

3 Ears _______________Hearing (e.g. Whisper at 2 meter)

_________ Nose ____________

4 Teeth & Gums ________________________Tongue ______________________________

5 Height cms Weight kg Girth at Nav el cms

BMI
Chest: Ex piration cms Inspiration cms
 Name of Candidate: _________________________________________

6 V ision (T o be checked by ey e specialist )

(Please provide the exact values)
Colour V ision (Pls √ Mark Applicable)
Rt Lt
Without glass Distance Normal Colour v ision

Near Total Colour Deficiency

With glass Distance Partial Colour Deficiency

Near If partial - pl. mention for which colour

Power of lens Spherical

Cy lindrical Signature of ey e specialist

Ax is

Y es No
Squint

Any other ey e disease if y es pl. giv e details

7 Audiometry Report

8 P.F.T Report

9 Heart Sounds ________________ Murmur Present Absent Details if present ___________

Arteries _________________________ Blood Pressure mm hg

(Please provide the exact values)
Sy s Dia

Pulse-Rate /min Character __________________________

10 Lungs ______________________________________________________________
1 1 Abdomen ____________________
Liv er ______________________Spleen ___________
12 Urinary and Genital Organs ______________________________________________

V enereal Disease ______________________________________________________

13 Special Conditions : Flat feet ___________________V aricose V eins ___________________
Hernia ____________________________________
Deformities ___________________

Scars _______________________________________________________

Identification marks:

1 _________________________________________________
2 ________________________________________________
14 Nerv ous Sy stem ____________________
Pupilary Reaction ______________________

Planters ______________________ Knee Jerks __________Rhomberg +v e -v e

15 Urine : Sp. Gr. ___________ Reaction __________Albumin __________Sugar ________

Microscopic (If required) ________________________________________________

Blood Haemoglobin g% Blood Sugar FBS/RBS Bl. Gr. +v e -v e

(Please provide the exact values) (Please provide the exact values)
S. cholesterol mg% S. Try gly . mg% S. Creat.
S. Bilirubin mg% SGPT units
16 Chest X-ray ________________________________________________________
17 E.C.G ________________________________________________________
18 Any other Inv estigations / clinical finding _____________________________________
 Name of Candidate: _________________________________________
6 COMMENT S AND RECOMMENDAT IONS :
(Pls √ Mark Applicable) (please refer standards for recruitm ent)
Fit Unfit
Remarks: ________________________________________________________

Date (dd/mm/y y y y ) Signature with Seal of Ex amining Doctor

Address of Ex amining Doctor

___________________________
___________________________
___________________________
Name: Registration No:
Contact No: Mobile: Clinic: Residence:

For office use only :

Date of receipt of original documents: ____________________PEM No.: ______________
MDMS No.: ______________
Medically Fit Temp. Unfit Unfit
Special Remarks: ____________________________________________________
Verification done by medical officer: Signature

Name ___________________ Date: ___________

Fitness certificate issued Y es No Fitness certificate sent on (date)______________