MEDICAL QUESTIONNAIRE /DECLARATION TO BE COMPLETED BY THE CANDIDATE

Name
Position Title
Age
Date of Birth
Address

:
:
:
:
:

Weight /Kg

Country of Origin:
Country of Residence:
Last Medical Exam Date:

Date of Birth
Height:(in Cm)
Sex

:
:
:

E-mail
Contact Number

:
:

Where and by Whom :

1. Have you ever suffered a serious accident?

2. Have you ever suffered from any work related illness?
3. How many separate spells of sickness absences have you had in the past 12 months?
4. What is the total number of days you have been off work sick during the past 12 months?
Have you ever had or been observed for any of the following , If yes give the details in the space below
Sl No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

Descritption

Yes

No

Heart Disease of any kind

Heart Attack
Heart Murmurs
High Blood Pressure (uncontrolled)
Abnormal Electrocardiogram
Shunt (e.g. pulmonary,cardiac)
Tuberculosis
Tumor of the Lung
Abnormal Chest Xray
Any other Lung disease
Tumor of gastrointestinal tract or other digestive disease
Liver disease
Kidney Disease
Gall bladder disease
Diabetes
Cancer / Tumors
HIV Positive
Hepatatis A/B/C/
Have you ever been refused employment of your health?
Have you ever been denied insurance because of Health or Physical
reasons?
Have you ever been hospitalized for mental illness.
Have you ever been unable to keep a job because of sensitivity to dust,
chemical etc.,?
BMI Calculation
Key to convert from Pounds to Kilo Gram : Multiply weight in Pounds by 0.45 (lb x 0.45 = Kg)
Key to convert from Inches to Centimeters : Multiply height in inches by 0.025 ( Inches x 0.025 = M)

SIGNATURE OF THE CANDIDATE:___________________.

DATE:______________________