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Medical Declaration Form

The document is a medical history form for applicants, requiring personal information such as name, gender, date of birth, and blood group. It includes a series of yes/no questions regarding the applicant's medical history, including vision, hearing, physical deformities, psychiatric conditions, and critical illnesses. The applicant must declare the accuracy of the information provided and acknowledge the potential consequences of false information.

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abdul
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4 views2 pages

Medical Declaration Form

The document is a medical history form for applicants, requiring personal information such as name, gender, date of birth, and blood group. It includes a series of yes/no questions regarding the applicant's medical history, including vision, hearing, physical deformities, psychiatric conditions, and critical illnesses. The applicant must declare the accuracy of the information provided and acknowledge the potential consequences of false information.

Uploaded by

abdul
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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Applicant ID Employee ID

(To be filled by HR) (To be filled by HR)

First Name Last Name

Gender

(Male/Female) Date of Birth (dd-mm-yyyy)

Blood Group

Candidate’s Medical History:

Candidate’s Medical Details Yes No Please provide the details


Do you have any defect or problem of vision?

Can you readily distinguish between the pigmentary colors?

Do you suffer from a degree of deafness which would prevent


your hearing of normal conversation?

Do you have any physical deformity / handicap?

Do you have any congenital disorder / abnormality?

Have you ever been diagnosed to have any Psychiatric ailment


including Depression, Anxiety Neurosis, Phobic Disorders,
Schizophrenia, Manic Depressive Psychosis or any other
Psychiatric illness?

Have you ever been diagnosed with an alcohol or drug abuse


problem? If yes, are you on treatment for the same?

Have you ever been disqualified on medical grounds from any


previous employment opportunity?

Have you ever been suffering from any Medical condition that
may require you to take Medical Leave over the next 12
months?

Have you had any form of critical illness or operation in the


last two years?

Have you ever been diagnosed to have Cancer, Tumor, Cyst or


any similar type of growth?
Have you ever suffered/are you suffering from any of the following? (Please tick whichever applicable):

Heart Attack Diabetes

High Blood Pressure Stroke

Night Blindness Valve Disorders

Asthma Slipped disc

Any other major illness/ disease that you are willing to disclose:

Please specify the name and dates of the COVID vaccination doses taken.

I declare that, to the best of my knowledge, the answers to the questions in this form are correct and
that I am not suffering from any disease/illness that I have not revealed.

I hereby declare that the information furnished above is true, complete, and correct to the best of my
knowledge and belief.

I understand that in the event of my information being found false or incorrect at any stage a
disciplinary action and legal action can be taken against me by the organization.

Signature:

Full Name:

Date (dd-mm-yyyy):

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