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Health Check-up

First Name:

Middle Name:

Companys Name:
Employee Code :

PASTE YOUR
RECENT
PASSPORT
SIZE
PHOTOGRAPH

Last Name:

Sr. No.:
Department:

Designation:

Declaration
I declare that the undersaid information is true and correct to the best of my knowledge.
If any of this information is found to be false / incomplete / incorrect the company can
cancel my appointment or terminate my service contract. No legal implications
regarding the same will be borne by Bureau Veritas (India) Pvt Ltd or
Bureau Veritas Certification (India) Pvt Ltd.
Date:
Thumb Impression / Signature of the candidate

Personal History
1. Smoking: ______________ Quantity:
2. Alcohol:
_________
3. Tobacco /Gutkha:
Regular:

day for-Years: _________

Quantity:
4.Any Other:

6. Bladder; Normal / Regular::


Coffee:

day for- Years:


5. Bowel : Normal /

7. Diet: Veg. /Non Veg.

8. Tea /

9. Vasectomy:____________________________
10. Any Allergies (Including
Drugs):_________________________________________________

Health History
Any Present Complains: _____________________________________________________
H/O Hypertension/Diabetes Mellitus/Heart Disease/Epilepsy :
______________________
Any other significant past illness: ______________________________________________
Any Accidents in past: _______________________________________________________
Any Surgical Intervention:____________________________________________________

Any Allergies (Including Drugs):________________________________________________


Any ongoing medications:
Any Occupational Related Health Hazards (Previous/Present):
___________________________

General Examination
Physical Parameters :
Height :

Weight :

Physical Deformities :
Conjunctiva : Pallor / Icterus :
Nail : Pallor / Icterus / Clubbing :
Edema : Pedal / Facial / Generalized :
Nodes / Glands / Thyroid :

Ears / Nose / Throat (ENT) External Examination


1. Ear Examination :
2. Tonsils :
3. Sinuses :
4. Throat:

CVS (Cardiovascular System)


1. JVP.:

2. Heart Rate :

4. B.P. :

5. Heart beat-location :

3. Rhythm :

RS (Respiratory System)
1.Shape of Chest :

2. Chest Expansion Measurements:

3. RR :

4. Air Entry

5. Breath Sounds :

6. Added Sounds :

GIT (Gastro Intestinal System)


1. Bowel Sounds:

2. Tenderness :

3. Ascites :

4. Palpable Mass :

5. Organomegaly :

6. Any Other :

Se
al

Certifying Physician
Qualifications
Reg. No.

PRE-EMPLOYMENT EVALUATION
Date: ____________

R/No.: ______________

First Name: __________________ Middle Name _______________ Last Name______________________


Companys Name: _______________________________________________________________________
Address: ______________________________________________________________________________
Tel No: _____________________________________ Email: ___________________________________

Declaration declare that the under said information is true and correct to the best of
my knowledge.
If any of this information is found to be false / incomplete / incorrect the company can
cancel my appointment or terminate my service contract. No legal implications

PAST YOUR
RECENT
PASSPORT
SIZE
PHOTOGRAPH

Regarding the same will be borne by Bureau Veritas (India) Pvt Ltd or
Bureau Veritas Certification (India) Pvt Ltd.

SafetyofPledge
Thumb Impression
Signature
the candidate
Amelio Personnel
From this day onwards, I solemnly affirm that I will rededicate myself to the cause of safety, health
and protection of environment and will do my best to observe rules, regulations and procedure
and develop attitudes and habits conducive for achieving these objectives.
I fully realize that accidents and diseases are a drain on my Organization and the National
economy and may lead to disablement, death, damage to health and property, social suffering
and general degradation of environment.
I will do everything possible for the prevention of accidents and occupational diseases and
protection of environment in the interest of self, my family, my organization, my workplace, my
community and the nation at large.

_________________________
Left Hand Thumb Impression
_____________
Place

_____________________
Candidates Signature
______________
Date

__________________________________
Certifying Occupational Health Physician

CERTIFICATE OF FITNESS

1. Name of the Company : __________________________________________________________


2. Serial No.

: ____________________________________________________

3. Name

: ____________________________________________________

4. Sex

: ____________________________________________________

5. Residence

: ____________________________________________________

6. Date of Birth

: ____________________________________________________

7. Physical Fitness

: Height: ____________

Weight: _______________

Chest

: Normal: ____________

Expanded: ____________

Eyesight

: Left : _____________

Right: ________________

8. General Examination

BP.: __________ CVS: ___________ RS: ___________ CNS: ________________


9. Others

: ____________________________________________________

10. Advice : _____________________________________________________________________


11. Descriptive Marks : I hereby certify that I have personally examined Mr. __________________, who
is desirous of being employed in factory and that his/her age as nearly as can be ascertained from
my examination is _______________ years and that he/she is FIT for employment in factory as an
adult child his/her descriptive marks are : ____________________
12. Reason for
1. Refusal of certificate : ____________________________________________________
2. Certificate being revoked : _________________________________________________

__________________________

Left Hand Thumb Impression of


Candidate

_______________

_____________________

Date

Certifying Industrial Health


Physician