PRE EMPLOYMENT MEDICAL FORM

Name of the Candidate:-

Fathers Name:-
Sex: - Age:-
Date of Birth:-
(As per certificate submitted for proof of age)
Nationality:-
Address:-
Candidates photograph to be
countersigned by examining physician

Personal and Past History

1. Are you allergic to any medicine/other substance? History of allergic rhinitis /Bronchitis?
Yes/No
2. Have you ever met with any accident leading to fracture of bone or other serious deformity?
Yes/No
3. Have you undergone any surgical operation for Hernia/Hydrocoele/or any major operation for thoracic,
neurological, orthopedic or abdominal conditions, If yes mention the nature of operation.
Yes/No
4. Have you ever suffered from convulsions/epileptic fits?
Yes/No
5. Are you suffering from any chronic disease like diabetics elitus, Ischaemic Heart disease, High Blood
pressure etc.?
Yes/No
6. Have you suffered from any Menstrual/Gynecological problem? (Applicable in Female candidates only)
Yes/No
7. Are you in habit of smoking or taking Alcohol or any other drug?
Yes/No
8. Are you suffering/Have suffered from any infectious diseases like Pulmonary Tuberculosis, Hepatitis B
infection?
Yes/No

Signature of the candidate

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Form No. HR/FRM/TAG/MF/15 Rev. No. 1.0 Effective Date: 01/01/2013

 PRE EMPLOYMENT MEDICAL FORM

Eye Examination (To be filled up by the Eye Specialist)

(a) Visual acuity

Right Eye _____________________ with/ without Glasses

Left Eye ______________________ with/ without Glasses

(b) Power of Corrective Glasses

Right Eye _______________________
Left Eye _______________________

(c) Color Perception

Right Eye __________________________
Left Eye __________________________

Conditions for Fitness

The colour vision should be normal as determined by Ishiharas Test Chart.

Acuity of vision without/with glasses should be 6/6 in each eye.
The power of corrective glasses should not exceed +- 4.0 D(Spherical/Cylindrical combined)
The Candidate should have binocular vision.
The Candidate should not be suffering from night blindness like Retinitis Pigmentosa.

The Candidate is declared Fit Unfit for Employment from Eye Examination point of
view (Kindly put a tick mark).

Signature of the Eye Specialist

Name___________________

Designation_______________

Office Address: _____________

___________________________

Medical Registration No._______

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Form No. HR/FRM/TAG/MF/15 Rev. No. 1.0 Effective Date: 01/01/2013

 PRE EMPLOYMENT MEDICAL FORM

General Clinical Examination (to be filled up by the Physician)

General Condition:-

Skin Condition:-

Visible Identification Marks (1)

(2)

Weight (in Kilograms)

Height (in centimeters)

Chest (Inspiration) - Cms

(Expiration) - Cms

Ears Nose Throat

Right

Left

Heart-

Blood Pressure-Systolic__________________________

Diastolic__________________________

Lungs-

Abdomen-Evidence of ascites/ lump/ tenderness

Liver-

Spleen-

Hydrocele/Hernia-

Congenital/ Acquired Deformity or anamoluses

Remarks (Any Relevant findings) - like Clubbing, Oedema, Jaundice, cyanosis, Lymphadenopathy, Palpable
Nodule/ Lump.

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Form No. HR/FRM/TAG/MF/15 Rev. No. 1.0 Effective Date: 01/01/2013

 PRE EMPLOYMENT MEDICAL FORM

Examination of CNS

Examination of Locomotor System

Gait- evidence of Limping:

Ability to Squat and to do sit-ups:

Amputation/ deformity/ Loss of function of any digits/ fingers/ toes/ joints or any part of upper and lower
extremities and spines.

The Candidate is declared Fit Unfit for Employment.

(Kindly put a tick mark)

Signature of the Examining Physician

Name_________________________

Designation ___________________

Official address: ___________________

Date: ___________ Medical Registration No.______________

Guidelines

Weight: 43.5 Kg is considered minimum weight for male candidates. Below 43.5 Kg is declared
underweight. For Female candidates the weight is 40 kg.

Height & Chest measurement: No minimum standard, no relation with weight.

Blood Pressure: Systolic Blood pressure not more than140 mm of Hg Diastolic Blood Pressure should not be
more than 90 mm of Hg.

If History/Clinical Examinations are suggestive of any disease, relevant investigation should be carried out.

Hernia/Hydrocele- candidates declared temporarily unfit till operated and cured.

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Form No. HR/FRM/TAG/MF/15 Rev. No. 1.0 Effective Date: 01/01/2013