1. The Candidate must ensure that a legally qualified and registered medical practitioner with minimum qualification as M.B.B.S. completes this form. Additional sheets may e attached if more space is required. !. The candidate is responsile for any costs associated with the preparation of this report. ". #lease hand o$er the complete form to your local %& at the time of 'oining. SECTION - 1 (to be filled by the Candidate) Candidate !e"onal Detail (ame first name middle name last name )ender Male *emale +ate of irth ++ , MM , ---- Blood )roup: Contact (o. .Moile/ .&esi./ Candidate# State$ent +o you ha$e any congenital defect,anormality0 -es (o. .If yes1 pro$ide details/ +o you ha$e any physical deformity,handicap or use any mechanical,physical assistance for moility0 -es (o. .If yes1 pro$ide details/ %a$e you had any form of serious illness or operation in the last two years0 -es (o. .If yes1 pro$ide date and details of surgery/ %a$e you een treated,hospitali2ed for cancer,Tumor,Cyst or any other growth0 -es (o. .If yes1 pro$ide details/ %as medical grounds een a reason for un3employment or you not performing a specific role in the past0 -es (o. .If yes1 pro$ide details/ %a$e you e$er suffered or suffering from any of the following0 paste a passport si2e color photograph attested y your consulting doctor %igh,4ow Blood #ressure Stro5e Bronchitis +iaetes,%ypoglycemia Arthritis #eptic 6lcer %eart +isease 7+ Tests #ositi$e Tuerculosis 8pilepsy )laucoma Color Blindness Thyroid Ailment %eart attac5 Slipped disc 4i$er disease Asthma %a$e you e$er suffered or suffering from any other illness or impairment not mentioned ao$e0 -es (o. .If yes1 pro$ide details/ Are you presently in a medical condition .including pregnancy/ that may require you to e away from wor5 in the ne9t 1! months0 -es (o. .If yes1 pro$ide details/ Candidate# De%la"ation I declare that to the est of my 5nowledge1 the answers to the questions in this form are correct and that I am not suffering from any disease,illness1 the presence of which I ha$e not re$ealed. I fully understand that any misrepresentation of this declaration could lead to the termination of my offer,appointment. I ha$e no o'ection to see5ing further information either directly from me or from my Consulting doctor or other appropriate doctor. In case of any discrepancy arising out of my declaration1 I will e undergoing the medical chec53up y the Company:s suggested medical clinic,doctor and their findings will e fully inding on me and any action thereon towards my employment will e accepted y me. Signature +ate Medi%al !"a%titione" Detail Se%tion - & (to be filled by the Medi%al !"a%titione") *ull name .as listed on the applicale State registry/ &egistration I+: #ostal Address: Contact (umer .+ay time/ 'ene"al E(a$ination Body wt: ;gs %eight: cms. #ulse: ,min. B#: mm %g De%la"ation I certify that I ha$e carefully e9amined Mr,Ms Son,+aughter of S)*E IS MEDICALL+ FIT ,NFIT fo" e$-loy$ent .ith &emar5s: Signature Seal +ate