Medical Fitness Self Declaration

Name PHANI KRISHNA BADIPATI

Date of Birth 4/8/1983 (Enter Date in DD-MMM-YYYY)

Age 36

Blood Group B+

S.NO Question Selection Remarks

1 Have you suffered from any major illness? If yes, please give details.
s
2 Have you been operated upon any time or advised If yes, please give details.
surgery?
s
3 Have you been hospitalised for any illness? If yes, please give details.
s
Do you suffer from any of the following?

Tubercul
Diabetes Anemia Epilepsy Malaria
Hyperten Palpitati osis
4
Breathle Jaundice
sion on ssness
Any Other Chronic Illness If yes please give details
s
Do you suffer from any ailments of the following?

5 Kidneys Liver Joints Eye Ear

Any Other Ailments If yes, please give details.
s
If yes , please give details medicines and since
6 Are you currently taking any medication how long
s
Do you have any eyesight loss or condition, including
colour vision, that would affect your ability to perform NO
duties?

Do you wear any spectacles or contact lenses? If yes YES SHORT SIGHT
for what reason? (eg short sight, reading)

Do any of your family members suffer from ailments

7 like diabetes, hypertension, etc.? If yes, please give details.
s
Have you been certified medically unfit in the past for
8 any employment? If yes, please give details.
s
9 Do you have any known allergy to any medicine or any If yes, please give details.
other substance or weather?
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10 Do you have any handicap or disability? If yes, please give details.
s
11 Are you a smoker?
s
12 Do you consume Alcohol
s
13 Do you consume Narcotic Drugs
s
14 Any other information you feel to declare NONE

I CERTIFY THAT THE ABOVE INFORMATION GIVEN IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF

Signature with Date

Name ( PHANI KRISHNA BADIPATI )