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7.

Physician

Near City Pride Kothrud

Ph. No. 020 65210207 / 25452280


Note : The Fitness / Unfitness will be indicated by Pinnac Diagnostic Centre directly to Reliance
Office not to individual candidate

RELIANCE INFOCOMM LIMITED


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 strictly confidential)

1.

PERSONAL DETAILS :Name :


(Surname)

(Other names)

Address :
Birth Place :
Intended Occupation :
2.

Date of Birth :

Religion

Marital Status :

Sex : M / F

FAMILY HISTORY : Has anyone of your family suffered from Cancer, Diabetes, Tuberculosis,
Epilepsy, Mental or Nervous disease?
AGE

IF LIVING
HEALTH (GOOD. BAD.
FAIR)

AGE AT
DEATH

IF DEAD
CAUSE OF DEATH

FATHER
MOTHER
BROTHERS (NO)
SISTERS (NO)
HUSBAND/WIFE
CHILDREN (NO)
3.

PERSONAL HISTORY :Are you in good health and capable of full work
Type of previous occupation?
Have you ever suffered from an occupational disease or injury ?
Have you every been discharge or rejected on medical grounds?
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 illnesses: Yes/No
Heart 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
CTv Brochitis : Yes/No Nervous/Mental disease of any kind : Y / N
Kidney disease : Yes / No:
Veneral Disease : Yes / No :
Malaria : Yes / No :
Dermalitis or any skin disease : Yes/No:
Typhoid fever : Yes / No :
Any allergy : Yes / No
Sinusitis : Yes / No :
Ear trouble : Yes / No
Operation or injuries : Yes / No
Menstural History L.M.P. :
Do you have any physical handicap : Yes / No

4.

I declare that the above statements are true and complete to the best of my knowledge and belief
and I agree that the 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 its service.

Date :
5.

Signature of Prospective Employee :


RESULTS OF PHYSICAL EXAMINATION:
1.

General Appearance

2.

Throat

Tonsils

3.

Ears

Hearing E.G. Whissper 20 ft

4.

Teeth & Gums

5.

Vision Distant : R.E.

L.E.

Corrected R.E.

L.E.

Near

L.E.

Corrected R.E.

L.E.

Thyroid

7.

Nose
Tongue

: R.E.

Eye Disease
6.

Glands

Colour Vision

Height

Chest. Exp.

Weight

Girth at Navel

Insp

Heart Sounds

Murmurs

Arteries

Blood Pressure

8.

Lungs

9.

Abdoman

10.

Urinary and Genital Organs

Liver

Spleen

Venereal Disease
11.

Special conditions : Flat feet

Varicose Venis

Hernia

Deformities

Scars
Identification Marks
12.

Nervous System

Pupilary Reaction

Plantars
Urine : Sp. Gr.

Knee Jerks
Reaction

Rhomberg
Albumin

Sugar

Microscopic (if required)


Blood Hemoglobin

6.

Date :

13.

Chest X-ray / Screening

14.

E.C.G.

15.

Other Investigations, if any

Blood Sugar

COMMENTS & RECOMMENDATIONS :

Examined by :

Blood Group