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Medical Declaration Form Template

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ancil.gonsalves00
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418 views1 page

Medical Declaration Form Template

Uploaded by

ancil.gonsalves00
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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MEDICAL DECLARATION FORM

Medication/Remarks

Conditions (If Yes, Plz Specify) No Yes

Any Allergy (Medical & Food)?


Any critical illness for which you are under treatment or for which you have
previously undergone treatment?
Do you suffer from frequent headaches/ migraines?

Are you suffering from Heart Disease / Cholesterol / High Blood pressure ?

Do you have any breathing issues?

Any illness that we should be informed about?

Do you consume Alcohol?

Do you Smoke?

Have you Undergone Any Surgery in last six month?

Have you ever failed any medical examination?

DECLARATION:

*I hereby declare that, to the best of my knowledge there is nothing on grounds of health which would
preclude me from meeting the conditions of employment and performing my duties in a consistent and
satisfactory manner. I also declare that I am fully competent, fully capable and available to undertake the
duties of the post.

I ________________declare that the above is true to the best of my knowledge and I accept that if I make a
false declaration I will be liable for disqualification from my appointment to the position.

Name:

Signature of Candidate:

Date:

INTERNAL:

PREPARED AND REVIEWED BY: HR

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