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7/23/2019 Pre Empl Medical Form (2) (1)
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Human Resources Department Pre- Employment Medical Check-list form
This is a confidential document and will be sealed and stored in employee file.
Name Date of Birth Nationality
Weight Height Blood Group
Personal History ( Please write Yes / No in the space provided )
Smoking Alcohol Tobacco
Using contact lenses Surgery on eyes
Are you allergic to any medicines or Injection?
Atypical Infections?
Past and Present Illness ( Please write Yes / No in the space provided )
Asthma Polio TB
Venereal disease Diabetes
Kidney disease Liver Disease
High Blood pressure Major injuries
Hospitalisation Chronic Debility
Surgery undergone Mouth Disease Hyper tension
Eye/Ear/Nose/ Throat Disease Deformity of Spine or any Limb
Thyrotoxicosis and Pituitary disorders Blood transfusion taken
Chronic Obstructive Pulmonary Disease Neurological disorder
Lymphadenopathy Any other diseases
Family History ( Please write Yes / No in the space provided )
Asthma Heart disease High Blood Pressure
TB Diabetes Cancer
Psychiatric illness Any other diseses
Past Occupational History
Oganisation
1
2
Signature of the candidate Date
Signature of Witness ( HR ) Date
I am the undersigned, Certified that, the particular given by me in the foregoing above are true, complete to the best of my
knowledge and belief. If any of this information is found to be false/incomplete/incorrect, the company can cancel my
appointment letter or terminate my service contact.
Designation Service ( year ) Past occupational illness
Heart Disease
Psychiatric illness
Bleeding disorders
Skin Disease
Garry Miranda Cacho
78kg 5ft 6in.
9th of Dec 1978 Filipino / Philippines
A+
No
No
No
No
Yes
No
No
No
No
No
No
Yes
No
No
No
No
No
NoNo
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
30th of Dec 2015
7/23/2019 Pre Empl Medical Form (2) (1)
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