Reliance Power Limited

Pre-Employment Medical Examination

Prospective employee should fill Section 1 to 4. The Examination Medical Officer will fill Section 5 & 6. Confidentiality of information will be maintained.

NAME OF THE HUMAN RESOURCE EXECUTIVE – Ms. Madhura Gupte

1. PERSONAL DETAILS :
Name __________________________________________________________________
(Surname) (Other name)
Address: ________________________________________________________________

Birth Place : ______________ Date of Birth _____________ Religion_____________

Intended Occupation: (Desk Job / Field Job). If Field Job, Nature of Work – _______________

Marital Status ____________ Sex ____________

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

IF LIVING IF DEAD
AGE HEALTH (GOOD,BAD, FAIR) AGE AT DEATH 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 ___________________________
Types of previous occupation? ________________________________________
Have you ever suffered from an occupational disease or injury ?
Have you ever been discharged 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 illness: 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._____ 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.___
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 : _____________ 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 ft.___________ Nose _______

Affix your passport
size photograph
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._____

6. Height ____________ Chest Exp. _____________ Insp.__________ Photograph to be duly attested

by the examining doctor
Weight____________ Girth at Navel_____________________________

7. Heart-Sounds ________________ Mummurs __________________

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 Veins ____________

Hernia ____________________ Deformities _______________

Scars____________________________

Identification Marks _____________________

12. Nervous System _________________ Pupillary Reaction __________________

Plantars ______________ Knee Jerks ____________ Rhomberg’s ____________

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 Investigation if any _________________

6. COMMENTS AND RECOMMENDATIONS: