Document No Version

MEDICAL EXAMINTATION REPORT

MTIPL/HR/F0006 1

Date :

Name : Sex : Age :

Position applied for :
Married/ Unmarried : Sons : Family Planning Operation :
Daughters : Tubectomy/ Vasectomy :
I declare that the particulars given below are true, complete and correct to the best of my knowledge & belief. If any of this
information is found to be false/ incorrect, the company can cancel my appointment letter or terminate my service
contract. The decision given by the Human Resources Department will be acceptable to me and will be binding on me and I
will not make any complaint regarding the same to anybody.

Signature of the candidate

(A) Past & Present Illness/ Disease :
Asthama Epilepsy High Blood Pressure Heart Disease

Diabetes T.B. Venereal Disease Skin Disease

Hospitalization History Alergies Family History

(B) Measurements Height Weight Chest Abdomen Built - Strong/ Average/ Poor

(C) Eye Vision Right Left Other diseases of eyes

Glasses
W/o Glasses

(D) Ears (Audiometry) :

(E) Cardiovascular System : B.P. Pulse

1. Urine - Alb Sugar 3. Haemogram 5. SGPT (Liver)

Investigations :

2. Screening/ X - Ray 4. Blood Group 6. Others

I declare him fit/ unfit _________________________________________________________________________________

Any specific observation _______________________________________________________________________________

_______________________________________________________________________________

Signature of Doctor