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UsrsaplettersPre-Employment Medical Form

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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Mahesh Yadav
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4K views2 pages

UsrsaplettersPre-Employment Medical Form

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.

Uploaded by

Mahesh Yadav
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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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