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Important Instructions:


1. The Candidate must ensure that a legally qualified and registered medical practitioner with minimum qualification as
M.B.B.S. completes this form. Additional sheets may e attached if more space is required.
!. The candidate is responsile for any costs associated with the preparation of this report.
". #lease hand o$er the complete form to your local %& at the time of 'oining.
SECTION - 1 (to be filled by the Candidate)
Candidate !e"onal Detail
first name middle name last name
)ender Male *emale
+ate of irth ++ , MM , ---- Blood )roup:
Contact (o. .Moile/ .&esi./
Candidate# State$ent
+o you ha$e any congenital defect,anormality0
-es (o. .If yes1 pro$ide details/
+o you ha$e any physical deformity,handicap or use any mechanical,physical assistance for moility0
-es (o. .If yes1 pro$ide details/
%a$e you had any form of serious illness or operation in the last two years0
-es (o. .If yes1 pro$ide date and details of surgery/
%a$e you een treated,hospitali2ed for cancer,Tumor,Cyst or any other growth0
-es (o. .If yes1 pro$ide details/
%as medical grounds een a reason for un3employment or you not performing a specific role in the past0
-es (o. .If yes1 pro$ide details/
%a$e you e$er suffered or suffering from any of the following0
paste a passport
si2e color
attested y your
consulting doctor
%igh,4ow Blood #ressure Stro5e Bronchitis +iaetes,%ypoglycemia
Arthritis #eptic 6lcer %eart +isease 7+ Tests #ositi$e
Tuerculosis 8pilepsy )laucoma Color Blindness
Thyroid Ailment %eart attac5 Slipped disc 4i$er disease Asthma
%a$e you e$er suffered or suffering from any other illness or impairment not mentioned ao$e0
-es (o. .If yes1 pro$ide details/
Are you presently in a medical condition .including pregnancy/ that may require you to e away from wor5 in the ne9t 1!
-es (o. .If yes1 pro$ide details/
Candidate# De%la"ation
I declare that to the est of my 5nowledge1 the answers to the questions in this form are correct and that I am not suffering from
any disease,illness1 the presence of which I ha$e not re$ealed. I fully understand that any misrepresentation of this declaration
could lead to the termination of my offer,appointment. I ha$e no o'ection to see5ing further information either directly
from me or from my Consulting doctor or other appropriate doctor. In case of any discrepancy arising out of my declaration1 I
will e undergoing the medical chec53up y the Company:s suggested medical clinic,doctor and their findings will e fully
inding on me and any action thereon towards my employment will e accepted y me.
Signature +ate
Medi%al !"a%titione" Detail
Se%tion - & (to be filled by the Medi%al !"a%titione")
*ull name .as listed on the applicale State registry/
&egistration I+:
#ostal Address:
Contact (umer .+ay time/
'ene"al E(a$ination
Body wt: ;gs %eight: cms.
#ulse: ,min. B#: mm %g
I certify that I ha$e carefully e9amined Mr,Ms
Son,+aughter of
S)*E IS MEDICALL+ FIT ,NFIT fo" e$-loy$ent .ith
Signature Seal +ate