MEDICAL QUESTIONAIRE

Marital status (please tick one)

Single ___*____ Married _________ Other (Divorcee/widow)________

Gender: Male _____*_____Female __________

Do you have any children?

Yes _______ No _____*___

If YES then kindly mention the number of children: _________.

If NO then, are you having any plans to conceive within a year?

Yes No *

Answer the following question with YES or NO

Do you have any physical disability? Yes No*

Do you use hearing aids or contact lenses/glasses? Yes No *

Do you have health insurance? Yes No *

Have you been treated for any major illness in the last 2 years?

Yes No *

Have you fallen sick in the past six months? Yes No *

If yes then kindly mention the type of sickness:_____________________________.

Have you been hospitalized for a period of 7 days or more in the past 5 years?

Yes No *

Have you undergone a surgery in the last 2 years? Yes No *

If YES then specify the date __________ and the type of surgery
undergone__________________________________________________________.
Do you suffer from:

HIV / any other STDs Yes No *

Hypertension/ BP Yes No *

Heart Diseases Yes No *

Epilepsy Yes No *

Diabetes Yes No *

Asthma Yes No *

Migraine Yes No *

Do you have any illness that requires you to be constantly on medication?

Yes No *

If yes then specify which one:________________________________

Have you ever been addicted to drugs or alcohol?

Yes No *

Does your family have a history of any of the following diseases?

Asthma _______

Heart disease _______

Cancer __________

Have you ever been infected by any waterborne diseases? Yes No *

If yes then mention which one:___________________

Allergies if any:

Are you under any legal obligation to your previous employer? Yes No *
If yes then please clarify_______________

THANK YOU