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    UsrsaplettersPre-Employment Medical Form

    Uploaded by

    Mahesh Yadav
    1) The document is a pre-employment medical examination form for Reliance Industries Limited's retail business. 2) It collects personal and family medical history details from prospective employees including any past or current illnesses. 3) A physical examination is then conducted by a medical officer who evaluates various body systems and records findings such as vision, hearing, respiratory system etc. Laboratory tests are also performed. 4) The medical officer finally determines if the candidate is medically fit for the intended job and notes any comments.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    UsrsaplettersPre-Employment Medical Form

    Uploaded by

    Mahesh Yadav
    3K views2 pages
    1) The document is a pre-employment medical examination form for Reliance Industries Limited's retail business. 2) It collects personal and family medical history details from prospective employees including any past or current illnesses. 3) A physical examination is then conducted by a medical officer who evaluates various body systems and records findings such as vision, hearing, respiratory system etc. Laboratory tests are also performed. 4) The medical officer finally determines if the candidate is medically fit for the intended job and notes any comments.

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    1) The document is a pre-employment medical examination form for Reliance Industries Limited's retail business. 2) It collects personal and family medical history details from prospective employees including any past or current illnesses. 3) A physical examination is then conducted by a medical officer who evaluates various body systems and records findings such as vision, hearing, respiratory system etc. Laboratory tests are also performed. 4) The medical officer finally determines if the candidate is medically fit for the intended job and notes any comments.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    3K views2 pages

    UsrsaplettersPre-Employment Medical Form

    Uploaded by

    Mahesh Yadav
    1) The document is a pre-employment medical examination form for Reliance Industries Limited's retail business. 2) It collects personal and family medical history details from prospective employees including any past or current illnesses. 3) A physical examination is then conducted by a medical officer who evaluates various body systems and records findings such as vision, hearing, respiratory system etc. Laboratory tests are also performed. 4) The medical officer finally determines if the candidate is medically fit for the intended job and notes any comments.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    PHOTOGRAPH

    TO BE AFFIXED

    Reliance Industries Limited


    Retail Business

    PRE-EMPLOYMENT MEDICAL EXAMINATION


    (Prospective employee should fill in Section 1 to 4. The Examining Medical Officer will fill in Section 5&6 All details given
    below will be treated as confidential)
    -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    1. PERSONAL DETAILS :

    Name: ……………………………………………………………………………………………………………………
    (Surname) (Other Name)
    Address: ………………………………………………………………………………………………………………………………

    Birth Place: ………………….. Date of Birth: ………………………….. Religion: ……………………………………….

    Intended Occupation: ………………………. Marital Status: ……………………… Sex: …………….………………….


    -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    2. FAMILY HISTORY: Has anyone of your family suffered from Cancer,
    Diabetes, Tuberculosis, Epilepsy, Mental or Nervous disease?

    IF LIVING
    Age HEALTH (GOOD, BAD, FAIR) AGE AT CAUSE OF DEATH
    DEATH
    FATHER
    MOTHER
    BROTHER (NO.)
    SISTER (NO.)
    HUSBAND / WIFE
    CHILDREN (NO.)

    3. PERSONAL HISTROY

    Are you in good health and capable of full work ________________________________________________________


    Types of Previous Occupation? ______________________________________________________________________
    Have you ever suffered from an occupational disease or injury?
    Have you ever been discharged or rejected on medical ground?
    Date of last Vaccination ____________________________________________________________________________
    Have you ever suffered from any of the following (Answer Yes or No. If yes give details)
    Rheumatic Fever: Yes / No. ___________________ Any other illness: Yes / No. ________________________
    Hear trouble: Yes / No. _______________________ Jaundices : Yes / No. _____________________________
    Stomach or other digestive disorder: Yes / No. _________ Diabetes: Yes / No. _______________________________
    Asthma: Yes/No. _____ Pleurisy: Yes/No. ________ Fits Fainting or dizziness : Yes/No.: _________________
    Pulm T.B.: Yes/No. _____ Chr, Bronchitis:Yes/No. ___ ___ Nervous/Mental disease of any kind:Yes/No. __________
    Kidney disease: Yes / No. ____________________ Veneral disease : Yes / No. _________________________
    Malaria: Yes / No. ___________________________ Dermatitis or any skin disease :Yes/No. ______________
    Typhoid fever: Yes / No. ______________________ Any allergy or: Yes / No. __________________________
    Sinusitis: Yes / No. __________________________ Ear trouble : Yes / No. _____________________________
    Operation or injuries: Yes / No. ________________ Menstrual history L.M.P: Yes / No. __________________
    Do you have any physical handicap: Yes / No. ___________________________________________________________
    Are you Pregnant : Yes / No/ Not Aware
    (Chest X Ray should be avoided in case of pregnancy)
    I declare that the above statements are true and complete to the best of my knowledge and belief and I agree that the
    4.
    results of this medical examination in general terms may be revealed to the company if required I also fully
    understand that if any of the said statements if proved wrong the company may have unwillingly engaged my services
    and I shall therefore have no claim against the company, if for these reasons I am discharged from it’s service.

    Date: ……………………….. SIGNATURE OF PROSPECTIVE EMPLOYEE: …………………………


    5. RESULTS OF PHYSICAL EXAMINATION

    1. General Appearance __________________________________ Skin __________________________________

    2. Throat ______________________ Tonsils ___________ Thyroid ____________ Glands __________________

    3. Ears _________________ Hearing E.G. Whisper 20 . _______________ Nose _________________________

    4. Teeth & Gums _________________________________ Tongue _____________________________________

    5. Vision Distant : R.E. __________ L.E. ______________ Corrected R.E. _______________L.E. ____________

    Near: R.E ___________ L.E. ______________ Corrected R.E. _______________L.E. ____________

    Eye Disease _______________________________ Colour Vision ____________________________________

    6. Height ________________________________ Chest Exp. _____________________ Insp. ________________

    Weight _______________________________ Girth at Navel _______________________________________

    7. Hearth sounds ________________________ Murmurs ____________________________________________

    Arteries _____________________________ Blood Pressure ________________________________________

    Pulse – Rate __________________________Character ____________________________________________

    8. Lungs ____________________________________________________________________________________

    9. Abdomen ____________________________ Liver __________________ Spleen _______________________

    10. Urinary and Genital Organs ___________________________________________________________________

    Venereal Disease ____________________________________________________________________________

    11. Special Conditions : flat feet __________________________ Varicose Venis ___________________________

    Hernia ________________________________ Deformities __________________________________________

    Scars _____________________________________________________________________________________

    Identification Marks _________________________________________________________________________

    12. Nervous System _________________________________ Pupilary Reaction ____________________________

    Plantars _________________________ Knee Jerks __________________ Rhomberg ____________________

    Urine : Sp. Gr. ____________ Reaction ____________ Albumin ____________________ Sugar ____________

    Microscopic (if required) ______________________________________________________________________

    Blood Haemoglobin ___________________ Blood Sugar ______________ Blood Group __________________

    13. Chest X-Ray / Screening _______________________________________________________________________

    14. E.C.G. : _____________________________________________________________________________________

    15. Other Investigations, if any _____________________________________________________________________

    16. Medically Fit: Yes / No __________ Comments/Suggestions: _____________________________

    DATE: …………………… EXAMINED BY: ………………………………


    (Registration Stamp of Doctor)

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