8/12/2019 Medical Certificate of Fitness & Health

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Important Instructions:

MEDICAL CERTIFICATE OF FITNESS

1. The Candidate must ensure that a legally qualified and registered medical practitioner with minimum qualification asM.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

(ame 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 yes pro$ide details/

+o you ha$e any physical deformity,handicap or use any mechanical,physical assistance for moility0

-es (o. If yes pro$ide details/

%a$e you had any form of serious illness or operation in the last two years0

-es (o. If yes pro$ide date and details of surgery/

%a$e you een treated,hospitali2ed for cancer,Tumor,Cyst or any other growth0

-es (o. If yes pro$ide details/

%as medical grounds een a reason for un3employment or you not performing a specific role in the past0

-es (o. If yes pro$ide details/

%a$e you e$er suffered or suffering from any of the following0

paste a passi2e colo

photograattested y

consulting d

%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 yes 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!months0

-es (o. If yes pro$ide details/

8/12/2019 Medical Certificate of Fitness & Health

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Candidate# De%la"ation

I declare that to the est of my 5nowledge the answers to the questions in this form are correct and that I am not suffering frany disease,illness the presence of which I ha$e not re$ealed. I fully understand that any misrepresentation of this declaraticould lead to the termination of my offer,appointment. I ha$e no o'ection to see5ing further information either direcfrom me or from my Consulting doctor or other appropriate doctor. In case of any discrepancy arising out of my declarationwill e undergoing the medical chec53up y the Companys suggested medical clinic,doctor and their findings will e fullyinding 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 Ea$ination

Body wt: ;gs %eight: cms.

#ulse: ,min. B#: mm %g

De%la"ation

I certify that I ha$e carefully e9amined Mr,Ms

Son,+aughter of

S*E IS MEDICALL+ FIT ,NFIT fo" e$loy$ent .ith

&emar5s:

Signature Seal +ate