HINDUSTAN GROUP OF INSTITUTIONS

Chennai 600 016

HEALTH DECLARATION BY CANDIDATE / EMPLOYEE

Name: ……………………………………………………………………

Post Applied for: ……………………………………………………………………

Address: ……………………………………………………………………

……………………………………………………………………

D M Y
Date of Birth: Gender: Male / Female

Kindly answer all the following questions:

1. Do you usually cough first thing in the morning? Yes  No 

2. Do you usually cough during the day or at night? Yes  No 

3. Do you usually cough up sputum? Yes  No 

4. Do you ever cough up blood? Yes  No 

5. How often do you get a common cold in a year? __________

6. Are you ever troubled by breathlessness (shortness of breath) or asthma? Yes  No 

7. Does your chest ever make a wheezing or whistling sound? Yes  No 

8. Does the weather, dust, pollen affects your chest, nose or skin? Yes  No 

9. Have you ever had?

a. Chest Operation Yes  No 

Form No. HGIHRD/03/Issue 1/ Revn 1/d.1-Jul-15

 HINDUSTAN GROUP OF INSTITUTIONS

Chennai 600 016

b. Bronchitis Yes  No 

c. Pneumonia Yes  No 

d. Pulmonary Tuberculosis Yes  No 

e. Bronchial Asthma Yes  No 

10. Have you suffered from swelling of feet or face? Yes  No 

11. Have you ever suffered from heart trouble? Yes  No 

12. Have you suffered from a specific allergic condition? Yes  No 

13. Have you ever had a fit? Yes  No 

14. Have you ever had kidney stone(s)/suffered from kidney disease? Yes  No 

15. Have you ever suffered from jaundice? Yes  No 

16. Have you ever suffered any chronic illness like:

a. Acid peptic disease Yes  No 

b. Hypertension Yes  No 
c. Diabetes Yes  No 
d. Psychological illness Yes  No 
e. Others. Yes  No 

If Yes, please specify: ………………………………………………………………………

……………………………………………………………………………………………….

17. Have you ever had ear discharge? Yes  No 

18. Have you ever suffered from reduced hearing/degree of deafness? Yes  No 

19. Have you ever suffered from difficulty in distinguishing colours? Yes  No 

20. Have you ever had skin problems? Yes  No 

If Yes, where?: ………………………………………………………………………………..………………..

Form No. HGIHRD/03/Issue 1/ Revn 1/d.1-Jul-15

 HINDUSTAN GROUP OF INSTITUTIONS

Chennai 600 016

…………………………………………………………………………………………………………………….

21. Have you ever had muscle, bone or joint related problems such as backache,
knee pain etc? Yes  No 

If Yes, please specify: …………………………………………………………………………

………………………………………………………………………………………………….

………………………………………………………………………………………………….

22. Have you ever had any surgical operation on any part of your body? Yes  No 

If Yes, please specify: ……………………..…………………………………………………..……

23. Did either of your parents or first degree relatives suffer from any chronic disease like Hypertension, Diabetes
Mellitus, Epilepsy or Cancer etc?
Yes  No 
If Yes, please give details: …………………………………….…………………………………..

………………………………………………………………….……………………..………………

………………………………………………………………………………………………….…..…

24. Have you ever suffered from blood diseases such as sickle cell anemia? Yes  No 

If Yes, please give details: …………………………………….………………….………………..

………………………………………………………………………………………..………..………

25. Are you aware of any birth defect or hereditary condition that you have? Yes  No 

If Yes, please give details: …………………………………….…………..………………………...

……………………………………………………………………………………………….……….…

26. Kindly write down your blood group if you know it.

………………………………………………………………………………………………………….

27.Do you smoke / use tobacco? Yes  No 

Form No. HGIHRD/03/Issue 1/ Revn 1/d.1-Jul-15

 HINDUSTAN GROUP OF INSTITUTIONS

Chennai 600 016

If Yes, How many cigarettes per day? (or) how many pan masala per day?

…………………………………………………………………………………………………….

Do you have any health issue due to smoking? ……………………………………………

28. Do you consume alcohol? Yes  No 

If Yes, what frequency per week? ………………………………………………………………………………

29. Do you take any medication? Yes  No 

If Yes, What kind and how often? …………………………………………………………….

…………………………………………………………………………………………………….

30. Kindly mention any medical problem that you have if it has not already been mentioned above?

……………………………………………………………………………………………………

………………………………………………………………………………………….…………

I declare that my answers to the questions in this Personal Statement are correct and true and that I
have not withheld any information. I also agree and understand the following:

- that I will have to undergo a medical examination should there be a need and requirement.

- that any omission or suppression of information about my health may lead to the immediate
termination of my appointment with Hindustan Group without notice / benefit, and I will be liable
to pay the costs of recruitment to Hindustan Group

- that the Hindustan Group is the sole authority to decide my fitness to work with them after the
medical examination and its decision will be final in this regard.

Name of Candidate: ____________________________________

Form No. HGIHRD/03/Issue 1/ Revn 1/d.1-Jul-15

 HINDUSTAN GROUP OF INSTITUTIONS

Chennai 600 016

Signature of Candidate: ____________________________________

Date: ____________________ ________________

Form No. HGIHRD/03/Issue 1/ Revn 1/d.1-Jul-15