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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 Heart trouble: Yes/No

Stomach or other digestive disorder: Yes/No. Diabetes : Yes/No

Any other illness: Yes/No Jaundices: Yes/No

Asthma: Yes/No Pulm T.B.: Yes/No

Pleurisy: Yes/No. Chr.Bronchitis : Yes/No

Fits,Fainting or dizziness: Yes/No Nervous/Mental disease of any kind : Yes/No

Kidney disease :

Veneral disease : Yes/No

Malaria :

Dermatitis or any skin disease : Yes/No

Typhoid fever : Yes/No Sinusitis : Yes/No Operation or injuries : Yes/No Do you have any physical handicap: Yes/No

Any allergy or : Yes/No Ear trouble : Yes/No Menstrual history L.M.P

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

3. Hearing E.G. Whisper. 20 ft

Ears

4. Teeth & Gums

5. Vision Distant :

Tongue

Corrected R.E

Glands

Nose

L.E

Near :

Corrected R.E

L.E

Affix your passport size photograph

6. Height

Chest

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

10. Urinary and Genital Organs

Venereal Disease

11. Special Conditions : Flat feet

Spleen

Varicose Veins

Hernia

Deformities

Scars

Identification Marks

12. Nervous System

Plantars

Urine : Sp.Gr

Microscopic (if required)

Blood Haemoglobin

13. Chest X-Ray/Screening

14. E.C.G.:

Pupillary Reaction

Knee Jerks

Reaction

Blood Sugar

Rhomberg’s

Albumin

Blood Group

15. Other Investigation if any

Sugar

6. COMMENTS AND RECOMMENDATIONS: