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PRE-EMPLOYMENT FITNESS FORM

CANDIDATES STATEMENT AND DECLARATION
The candidate must make the required statement below prior to his medical
examination and must sign the declaration appended thereto.

1. Personal Details:
Name: _____________________________________ Sex: Male/ Female

Date of Birth: _____________________________________ Age: ___________

Fathers / Husbands Name __________________________

Residence Address _________________________________

_________________________________

Phone No: _________________________________

Present posting: Type of job / Occupational hazard, if any ____________________

Marks of Identification:
1 ____________________________________________
2 ____________________________________________
2. History:

a) Personal History: Blood Group ____________

Marital Status: Married/ Unmarried

No of Children ________________

Diet: Veg / Non-Veg Alcohol: Yes / No

Other Habits: ________________ Smoking: Yes / No

b) Past History:
(i) Drug Allergy Yes/ No

(ii) Name of Medicine __________________________________________

(iii) Major Illness/Operations/Injuries with date

____________________________________________________________

(iv) Occupational Exposure:

Previous _____________________________ Duration with year________

Type of Work done __________________________________________

(Details of past exposure to any significant occupational hazards).

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(v) Female Candidate: Menstrual History: a) LMP: ________________________

b) History of miscarriages/abortions/ still births/ congenital malformation etc.

______________________________________________________________

(vi) Details of Vaccination/ Immunization ________________________

(vii) Have you suffered from any form of nervousness due to overwork or any other
cause? ______________________________________________________

(viii) Have you been examined and declared unfit for Govt. Service by a Medical
Officer/Medical Board, within the last three years? _______________________

c) Family Medical History: _____________________________________

Furnish the following particulars concerning your family:

Fathers age if living Fathers age at death

and state of health and cause of death

Mothers age if living Mothers age at death

and state of health and cause of death

DECLARATION

I declare all the above answers to be, to the best of my belief, true and correct.

I also solemnly affirm that I have not received disability certificate/pension on

Account of any disease or other condition.

Candidates signature: _______________

Date:
Place:

Note:
The candidate shall be held responsible for the accuracy of the
above statement/investigations. By willfully suppressing any
information, he will incur the risk of losing the appointment or
forfeiting all claims to superannuation allowance / gratuity, if
appointed.
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EXAMINING PHYSICIANS REPORT

Date ____________

Name: _________________________________
Recent
Sex: Male/ Female Colour
Date of Birth: _________ Age: __________ Photograph of
associate
General Appearance: __________________________

1. General Examination
a) Height: _______________ cm . .
b) Weight: __________ kg c) Chest _______________ cm
d) Temperature: __________C e) Pulse: _______________/min
f) Blood Pressure: __________ mmHg

g) Acuity of Vision:
Without glasses With glasses Colour
Vision
Distant Vision RE

LE Night
Blindness
Near Vision RE

LE

h) Skin condition: Normal/Abnormal Comment if any __________________

i) Teeth: Normal/Abnormal Comment if any __________________

j) Lymph nodes: Normal/Abnormal Comment if any __________________

k) ENT: Normal/Abnormal Comment if any __________________

2. Systemic Examination :-( Kindly mention detail history of systemic

Examination Past /Present findings).
a) Respiratory system: ____________________________________

b) Cardiovascular system: _____________________________________

c) Gastro-intestinal system: _____________________________________

d) Locomotor system:
Deformity /amputation _____________________________________

e) Central Nervous system: _____________________________________

f) Genito-Urinary system: _____________________________________

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g) Others: ____________________________________

3. Job Specific Test:-

Paint Shop/Deptt: - PFT, X-Ray Chest (PA View),
Complete Haemogram, Urine R/M.
Weld shop/Deptt: - PFT, X-Ray Chest (PA View),
Complete Haemogram.
Press shop/Deptt: - Audiometry, Complete Haemogram.

D.G.Room:- Audiometry, Complete Haemogram.

LPDC/HPDC/DC: - X-Ray Chest (PA View), PFT

Complete Haemogram, Urine R/M.

4. Remarks:
__________________________________________________________________

__________________________________________________________________

Signature and Seal of

Doctor with Reg No:

____________________