PRE-EMPLOYMENT MEDICAL Doc.

No: AI-QA-HSE-MED-020
FITNESS EXAMINATION Rev. No.: 00
PROCEDURE Date: 12TH Jan 2021

APPENDIX-2 PRE-EMPLOYMENT MEDICAL FITNESS FORM

PERSONAL DETAILS

Name Job Designation DOB Marital Sex Nationality

Status
Kartik Kumar Helper Single Male Indian
01/02/1999

MEDICAL DETAILS

Please tick box X Yes No Comments:

Are you at present under medical care X
1 or receiving treatment?
Are you currently taking medication, X
2 whether prescribed or not having
injections, using an inhaler or have
you recently done so, or are you on
any special diet?
Have you ever suffered from:
Fits, fainting, giddiness or any mental X
3 or nervous disorder?
Asthma, bronchitis, pneumonia or any X
4 other lung disorder?
5 Rheumatism, rheumatic fever, arthritis
or any other disorder of joints and X
muscles?
Chest pains, shortness of breath,
6 palpitations, high blood pressure or X
other disorder of the heart or
circulation?
Indigestion, peptic ulcer, diarrhea, X
7 constipation or any intestinal
complaint, hepatitis or other liver
disorder, diabetes?
8 Kidney, bladder or other genito-urinary X
disease?

9 Any injury, operation, physical defect or X

deformity?
10 Have you been a patient at a hospital, X
nursing home or special clinic?
11 Have you ever had any form of X
sexually transmitted disease?

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 PRE-EMPLOYMENT MEDICAL Doc. No: AI-QA-HSE-MED-020
FITNESS EXAMINATION Rev. No.: 00
PROCEDURE Date: 12TH Jan 2021

12 Non-smokers: Have you smoked in the X

past?
13 Smokers: How much do you smoke per X
day?
14 What is your average daily X
consumption of alcohol?
2. FAMILY’S MEDICAL HISTORY

Diabetics Tuberculosis Epilepsy

Asthma

Heart Disease Hypertension Stroke

If yes Provide Details:-

I declare that to the best of my knowledge and belief the answers to the above questions are
true and complete. I confirm that I have checked and found correct any answers that are not
in my handwriting. I grant permission for taking samples of blood, saliva and/or urine in
connection with this examination.

I understand that this statement will be forwarded to the Company’s medical Department.

Applicant’s Signature............................................Date........................................

(To be signed in the presence of Medical Examiner)

SUMMARY OF MEDICAL HISTORY OF Mr/Mrs…...................................................

Has the description. Applicant ever had or has now any of the following? If yes, give details
in the summary

Please tick box, whether normal or not X

Yes No
Yes No
1 Ear No 8 Endocrine disorder No
Infection/Sinusitis/V
ertigo
2 Nose, mouth or No 9 Hernia /Hydrocele/Piles/Fissures No
throat trouble
3 Colour No 10 Fistula/Appendicitis/Varicocele No
Blindness/Loss of
vision
4 Frequent No 11 Malaria/Tropical disease No

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 PRE-EMPLOYMENT MEDICAL Doc. No: AI-QA-HSE-MED-020
FITNESS EXAMINATION Rev. No.: 00
PROCEDURE Date: 12TH Jan 2021

Headaches/Fainting
5 Epilepsy/Mental No 12 Skin disease No
Illness
6 Hypertension No 13 Cancer or Tumor No

7 Diabetes mellitus No 14 Allergy to foods/Drugs No

Remarks:

MEDICAL EXAMINERS REPORT

If you answer YES to any of the following questions, please give full details with any
ascertainable cause as applicable

1 Cardiovascular system & blood pressure

Does the heart appear to be enlarged?
If YES, do you consider this to be slight,
moderate or marked?
Is there any irregularity of rhythm?
Is there any abnormality of the arterial pulses?
Are there any varicose veins?
2 Respiratory system

Is there any abnormality in the shape and

development of the chest?
Are there any abnormal physical signs in the
lungs?
3 Genito/Urinary & digestive system
Is the urine test abnormal?
Is a hernia present?
Is there any abnormal tenderness, enlargement
or other
4 Nervous system
Are there any signs of disease in the central
nervous system?
Is there anything to suggest a tendency to
psychiatric disorder?
5 Organs of special sense
Is there any affection of the eyes, ears, nose or
tongue

5. EXAMINATION RESULTS AND REPORT

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 PRE-EMPLOYMENT MEDICAL Doc. No: AI-QA-HSE-MED-020
FITNESS EXAMINATION Rev. No.: 00
PROCEDURE Date: 12TH Jan 2021

1. ECG Report.

2. TMT Report (For 50 years and Above age)

3. Audiometry (Fabricator/Grinder/Sand Blaster/Welder/Vehicle maintenance technician/Heavy

vehicle /Heavy machinery operator)

4. Vision Test
Vision No Spectacles With Spectacles Color Blindness
Near Distance Normal
Far Distance Red/Green Absent
Totally Absent

All original exams, results and tests should be attached to the Medical Fitness report Form

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 PRE-EMPLOYMENT MEDICAL Doc. No: AI-QA-HSE-MED-020
FITNESS EXAMINATION Rev. No.: 00
PROCEDURE Date: 12TH Jan 2021

5. Blood examinations Report: (Please attach the results of the following examinations or
indicate here below the results) All the original Investigation reports shall be attached

Complete Blood Liver Function Test Lipid Profile Renal Function Test
Count
Urine Routine Fating Blood Sugar
Examination Level.

Height weight Blood Pressure Pulse Rate BMI

OTHER FINDINGS:
He is found to be:
1. Fit for the position stated. Physique, scars, disabilities, mental
stability including behaviour, etc.
2. Unfit for the position stated.

• Pre-existing Diabetics (Fasting blood

Sugar above 140 mg/dl)
• Hypertension (BP above 150/95 mmHg)
• Known case of Ischemic Heart
Diseases.
• Known case of Liver Cirrhosis/Chronic or
recurring pancreatitis.
• Clinical evidence of any recurrent,
physically or socially disabling skin
disease or sensitivity is unacceptable
• Individuals on psycho-tropic medications
(e.g. tranquillizers, antidepressants,
narcotics, hypnotics) are unacceptable.

Physician’s Name: ……………………………………………………………………………………………

Name of the Hospital: ………………………………………………………………………………………..

Contact Number: …………………………

Signature: ………………………………………………………………………………………………………

Telephone: Stamp

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