Tata Motors Limited PASTE YOUR

Pre-Employment Medical Examination RECENT PASSPORT

SIZE PHOTOGRAPH
(Prospective employee should fill in Section 1 to 4 (Attested by the
The Examining Medical Officer will fill in Section 5 to 6 Examiner)
All details given below will be treated as confidential
Please √ Mark Where Applicable)

1 PERSONAL DETAILS:

First Name Middle Name Surname

Address:

City Pin:
Birth Place: Birth Date Religion
(dd/mm/yyyy)
For post applied Marital Status: Married / Unmarried Sex: M / F

2 FAMILY HISTORY:
Has any one of your family suffered from
Diabetes Hypertension Heart Disease Arthritis
Tuberculosis Asthma Cancer Epilepsy
Mental or Nervous Disorder Any other disease

IF LIVING IF DEAD

AGE HEALTH (GOOD, BAD, FAIR) AGE AT DEATH CAUSE OF DEATH

FATHER

MOTHER

BROTHER (NO.)

SISTER (NO.)

HUSBAND/WIFE

CHILDREN (NO.)

3 PERSONAL HISTORY: Yes No

Are you in good health and capable of full work
Have you ever suffered from an occupational disease or injury?
Have you ever been discharged or rejected on medical grounds?
Types of Previous Occupation (Pl. describe in brief about company, nature of work, duration in years)
Name of Candidate:
Have you taken any vaccination? Yes / No (If yes complete / partial)
Have you ever suffered from any of the following (Answer Yes or No. if yes, give details)

Y N Y N
Heart Disease Hypertension
Diabetes Chronic abdominal /digestive disorder
Kidney disease Hepatitis-B
AsthmaChronic Lung disease (e.g. bronchitis, pleurisy, pneumonia etc.)
Tuberculosis Malaria / Typhoid fever in last 6 months
Dermatitis or anyskin disease Venereal or Sexually Transmitted Disease
Epilepsy,Fits, fainting or dizziness Nervous / Mental disease of any kind
Any allergy Any chronic ear or hearing problem (e.g. sinusitis, rhinitis, otitisetc.)
Any major operation or injury Any other illnesses
Do you haveany physical handicap Details of any of above if "Yes"

(For female candidates only) Are you pregnant at present? Y / N Date of 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 in case I am
declared medically unfit due to any reason, I shall not be entitled for the employment in the company. However, the decision taken by
the company's doctor/s about my medical fitness will be final and binding to me.

Date (dd/mm/yyyy) Signature of Prospective Employee

5 RESULT OF PHYSICAL EXAMINATION:

(Examining doctor should ensure that candidate has filled up section 1 to 4)

1 General Appearance Skin
2Throat Tonsils Thyroid Glands
3 Ears Hearing (e.g. Whisper at 2 meter) Nose
4 Teeth & Gums Tongue
5 Height cms Weight kgs Girth at Navel cms
BMI
Chest: Expiration cms Inspiration cms
Name of Candidate:

6 Vision (To be checked by eye specialist)

Rt Lt Colour Vision (Pls √ Mark Applicable)

Without glass Distance Normal Colour vision
Near
Total Colour Deficiency
With glass Distance
Partial Colour Deficiency
Near
Power of lens Cylindrical If partial - pl. mention for which colour

Axis

Y N Signature of eyespecialist
Squint
Any other eye disease
If yes, pls. give details

7 Audiometry Report
8 P.F.T Report
9 Heart Sounds Murmur Present Absent Details if present

Arteries Blood Pressure mm hg

Sys Dia

Pulse-Rate /min Character

10 Lungs
11 Abdomen Liver Spleen
12 Urinary and Genital Organs
Venereal Disease
13 Special Conditions: Flat feet Varicose Veins
Hernia Deformities
Scars
Identification marks:
1
2
14 Nervous System Pupillary Reaction
Planters Knee Jerks Romberg +ve -ve

15 Urine: Sp. Gr. Reaction Albumin Sugar

Microscopic (If required)

Blood Hemoglobin g% Blood Sugar FBS/RBS Bl.gr. +ve -ve

S. cholesterol mg% S.Trygly mg% S.Creat.
S.Bilirubin mg% SGPT units

16 Chest X-ray
17 E.C.G
18 Any other Investigations / clinical finding
Name of Candidate:

6 COMMENTS AND RECOMMENDATIONS:

(Pls √ Mark Applicable) (Please refer standards for recruitment)

Fit Unfit

Remarks:

Date (dd/mm/yyyy) Signature with Seal of Examining Doctor

Address of Examining Doctor

Name: Registration No:

Contact No: Mobile: Clinic:
Residence:

For office use only:

Date of receipt of original documents: PEM No.:

MDMS No.:

Medically Fit Temp. Unfit Unfit

Special Remarks:

Verification done by medical officer: Signature

Name Date:

Fitness certificate issued Yes No Fitness certificate sent on (date)

EMPANELLED MEDICAL CENTRES: APOLLO - OWNED CLINICS

Clinic Contact
SL Clinic Location City State Clinic Address Clinic pin Clinic Email
details

9, #1-58/91/SS, Suresh Square,

chandanagar@apolloclinic.c
1 Chanda Nagar Hyderabad Telangana Madeenaguda, Seri Lingampally 500050 (040) 2304 6744 - 8
om
Mandal, Ranga Reddy District

7-1-621/109(61/3RT), Sanjeev
2 S.R. Nagar Hyderabad Telangana 500038 srnagar@apolloclinic.com (040) 2370 2237 - 9;
Reddy Nagar

37, Survey No.201, Hill Colony,

N.G.O’sColony Road,
vanasthalipuram@apollocli (040) 2412 1077 /
3 Vanasthalipuram Hyderabad Telangana Vanasthalipuram 500070
nic.com 2077/ 3077/ 4077
Residential Complex,
Vanasthalipuram

The Apollo Medical

Centre,2-20/6/A, 500032 (040) 3016 6677;
4 Kondapur Hyderabad Telangana hitechcity@apolloclinic.com
Kothaguda X Roads, Kondapur, 040 3016 6600
Hi-tech City

jubileehills@apolloclinic.co (040) 2360 9444/

5 Jubilee Hills Hyderabad Telangana 703-A, Road 36, Jubilee Hills
m 555/ 666

A-12, # 1-9-71/A/12/b, Rishab (040) 2712 6688,

asraonagar@apolloclinic.co
6 A.S. Rao Nagar Hyderabad Telangana Heights, Rukminipuri Housing 2713 4488,
m
Colony, A.S.Rao Nagar 27146688

2-1-520 to 526/2, First Floor,

nallakunta@apolloclinic.co (040) 2766 6016/
7 Nallakunta Hyderabad Telangana Vijaya Sri
m 46/ 56
Sai Celestia, Nallakunta

50–81–1/2, Plot 5,
Vizag, Dwaraka Andhra (0891) 258 5511 - 2,
8 Vishakapatnam Sheethammapeta, 530016 vizag@apolloclinic.com
Nagar Pradesh 254 8818
Visakhapatnam

The Apollo Clinic, Plot no. 3 & 4,

Survey no. 239 Qutbullapur (040) 4007 8444/
9 Nizampet Hyderabad Telangana 500072 nizampet@apolloclinic.com
mandal, R R Dist, Nizampet, 45/ 46
Hyderabad - Andhra Pradesh

Nyati Millenium Premises,

Cooperative Society Limited, vimannagar@apolloclinic.co (020) 2663 4331/
10 Viman Nagar Pune Maharashtra 411014
Shop No.S1 & Stilt Floor, Building m 32/ 34
"C", Viman Nagar

Centriole, Plot #90, Survey #129,

11 Aundh Pune Maharashtra 411027 aundh@apolloclinic.com (020) 2588 7961 - 4
130/1+2, ITI Road, Aundh

“AMBA VATICA”, Plot No. B-1,

Survey No. 16A/2, Wanowrie,
12 Wanouri Pune Maharashtra 411018 wanowrie@apolloclinic.com (020) 2683 0291/95
Khondawa Khurd, Taluka Haveli,
Pune

Shop No.: 14 to 20, City Pride

building, Sector - 25, Next to
13 Nigdi (Pimpri) Pune Maharashtra nigdi@apolloclinic.com (020) 27653312 /13
BHEL Chowk, Nigadi Pradhikaran,
Pune -411004

11, First Floor, Gaur Gravity, Plot

indrapuram@apolloclinic.co (0120) 640 2598/99;
14 Indirapuram Ghaziabad Uttar Pradesh No.8, Vaibhav Khand, 201014
m 8586999138
Indirapuram

Apollo clinic, GF-2,Baleshwar

079-30457147,
Square, Opp.: Iscon Temple, Off
15 Satellite Ahmedabad Gujarat 380015 satellite@apolloclinic.com 30465160,
SG High Way, Ahmedabad -
30426236
380015
 Clinic Contact
SL Clinic location City State Clinic Address Clinic pin Clinic Email
dedails

99, Bull Temple Road, basavanagudi@apolloclinic.

16 Basavanagudi Bangalore Karnataka 560019 (080) 2661 1236/7
Basavanagudi com

The Apollo Medical Centre,51,

koramangala@apolloclinic.c (080) 2563 3833;
17 Koramangala Bangalore Karnataka Jyoti Nivas College Road, 5th 560095
om 2563 3820/21
Block, Koramangala

54, First Floor, 12th Main Road,

18 HSR Layout Bangalore Karnataka 560102 hsr@apolloclinic.com (080) 2572 4235 - 8
HSR Layout

2012, 1st Floor, 100 Feet Road, indiranagar@apolloclinic.co

19 Indiranagar Bangalore Karnataka 560038 (080) 2521 4614/15
HAL 2nd stage, Indira Nagar m

65 Madhavaraya Mudliar Road frasertown@apolloclinic.co

20 Fraser Town Bangalore Karnataka 560005 (080) 2580 8084/85
(MM Road), Fraser Town m

23, Kalidasa Road, VV Mohlla,

21 Vijaynagar Mysore Karnataka 570002 mysore@apolloclinic.com (0821) 400 6040 - 2
Mysore

74/1, Bellandur Ring Road,

22 Bellandur Bangalore Karnataka 560037 bellandur@apolloclinic.com (080) 4022 2555
Varthur, Bangalore East

GYR Chambers, Opp. South Indian

23 Sarjapur Road Bangalore Karnataka Bank , Kaikondanahalli, Sarjapur sarjapur@apolloclinic.com (080) 2574 6371-73
Road, Bangalore – 560034

The Apollo Clinic, SJR

Maximus,No.35 &
36, 2nd Main Road, Next to DELL, sadashivanagar@apolloclini (080) 2331 5503,
24 Sadashiv Nagar Bangalore Karnataka
Vyalikaval, Sadashivanagar, c.com 5504
Bangalore -
560036, Karnataka

hc.alwarpet@apollospectra.
Apollo Day Surgery, No 12, CP
DAY CARE com; (044) 2467 2200,
25 Chennai Tamil Nadu Ramasamy Road, Alwarpet,
Alwarpet pragya.pandey@apollospec 2498 8865/66/67
Chennai - 600018
tra.com

Apollo Medical
Centre,No-30,FBlock, annanagar@apolloclinic.co (044) 2620 6666,
26 Anna Nagar Chennai Tamil Nadu
2nd Avenue, Annanagar East, m 26224505
Chennai - 600102

The Apollo Medical Centre,15/42,

kotturpuram@apolloclinic.c 044 - 24471212 /
27 Kotturpuram Chennai Tamil Nadu Gandhi Mandapam Road,
om 1155.
Kotturpuram, Chennai – 600085

The Apollo Clinic – Velachery, 044 - 2243 2370/

28 Velachery Chennai Tamil Nadu Plot No 46, 7th Street, Tansi velachery@apolloclinic.com 2243 3370 / 2243
Nagar, Velachery – 600 042 4370

The Apollo Medical Centre, No

044 - 28151066/
29 T'Nagar Chennai Tamil Nadu 175, GNChetty Road, T Nagar, tnagar@apolloclinic.com
5316/ 17 / 18
Chennai – 600017

The Apollo Clinic, Ambattur No.5,

Kambar salai Mogappair, (044) 2625 0799/
30 Ambattur Chennai Tamil Nadu ambattur@apolloclinic.com
Ambatturvillage, Chennai - 0778
600037, Tamil Nadu
EMPANELLED MEDICAL CENTRES: APOLLO – NETWORK CLINICS

Clinic Clinic Contact

SL City State Clinic Address Clinic email
Location details

The Apollo Clinic, Meena Bhawan,

Kanchan Road, Near Sahara Airlines rajeevkchandak@gmail.com (0361) 246 1473 / 246
1 Guwahati Guwahati Assam
Office, Bora , Service, Guwahati Shillong guwahati@theapolloclinic.com 1474.
Road, Guwahati 781 005

011-25918222/
The Apollo Clinic,C-70, Major Sudesh 25918333
Kumar Marg, Opp. Madhav Park,Near Mobile No: +91
2 Rajouri Garden Delhi Delhi rajourigarden@theapolloclinic.com
Main Market, Rajouri Garden, New Delhi 9711203302,
- 110027 9811061009
Fax: 011-25918444

The Apollo Clinic, Mann Complex, Anand adajan@theapolloclinic.com 0261 – 279 0202 /
3 Adajan, Surat Surat Gujarat
Mahal Road, Adajan, Surat – 395 009 apolloclinicsurat@gmail.com 279 5031

The Apollo Clinic

Phone : 0265 -
3/A, Bhagwati Park Society
4 Vadodara Vadodara Gujarat vadodara@theapolloclinic.com 2357333 /
Opp. Tube Company, Old Padra,
2327333
Vadodara - 390 020, Gujarat.

Ph.: (0497)-
kannur@theapolloclinic.com 2768041/42/43, Fax:
The Apollo Clinic, CW-35/2935, City
prasadpaickat@gmail.com (0497) - 2768 046.
5 Kannur Kannur Kerala Centre, Fort, Road.Kannur 670 001
premkumarmenon@rediffmail.com Phone: 040 - 2311
Kerala.
fawazabdulla@hotmail.com 8001 /8002 /
Fax: 040 – 2311 8003.

The Apollo Clinic

premkumarmenon@rediffmail.com Tel : 0471-2303010,
6 Trivandrum Trivandrum Kerala TC 12,1235-1, Law College Junction
apolloclinictvm@yahoo.com 2303017, 2303018
Vikas Bhavan P.O, Trivandrum - 695033

The Apollo Clinic

Plot No 50, Jai Vishwa Bharati Colony,
aurangabad@theapolloclinic.com
7 Aurangabad Aurangabad Maharashtra Opp Sapna Super Market, 0240 2354304, 2354306
nacgroup@nac.co.in
Chetak Ghoda Chowk,
Aurangabad 431005

The Apollo Clinic, The Emerald, Plot No.

8 Vashi Mumbai Maharashtra 195/B, Sector–12 Besides Neel Siddhi vashi@theapolloclinic.com 022 - 2788 1322 - 1325
Towers, Vashi, Navi Mumbai – 400 703.

The Apollo Clinic, Z-5, Z Shopping Centre,

Flower Valley, Off. Eastern Express (022) 2547 0011 / 2547
9 Thane Mumbai Maharashtra thane@theapolloclinic.com
Highway, Khopat, Thane (W), 5055
Maharashtra.400601

The Apollo Clinic, Madhuvan Building,

1st Floor, M G Road, Near Kala Hanuman
10 Kandivali Mumbai Maharashtra kandivali@theapolloclinic.com 022 – 2861 7416 – 18
Mandir , Kandivali – West, Mumbai –
400 067

The Apollo Clinic, 1st Floor, “A” Wing,

022 -2826 2741 / 2742 ;
11 Andheri East Mumbai Maharashtra Ambika Apartments, Mahakali Caves andherieast@theapolloclinic.com
28263734/35
Road, Andheri-East, MUMBAI-400 093

The Apollo Clinic,Ground Floor,

Eucharistic Congress Building No 1, 5, apolloclinicmumbai@gmail.com 022-22021166 /
12 Colaba Mumbai Maharashtra
Convent Street , Colaba, Mumbai colaba@the apolloclinic.com 8450982225 ( Clinic No)
400 001
 Clinic Clinic Contact
SL City State Clinic Address Clinic email
Location details

The Apollo Clinic, Suyojit Commercial

13 Nashik Nasik Maharashtra Complex, Mumbai Naka, Mumbai Agra nashik@theapolloclinic.com (0253) 2502001/2
Road, Nashik - 422 001

The Apollo Clinic,

Specimens Holdings Ltd
14 Berhampur Berhampur Orissa anil@apolloberhampur.com 0343-2548111
Bhaba Nagar 1st Line, Berhampur
760004

The Apollo Clinic, SCO 170-171, Madhya

15 Chandigarh Chandigarh Punjab hr.apollo.chd@gmail.com 0172-4006060
Marg, Sector 9C, Chandigarh 160 017

The Apollo Clinic, # 19, Cowley Brown

16 Coimbatore Coimbatore Tamil Nadu Road, R S Puram, Coimbatore - 641 002, coimbatore@theapolloclinic.com 0422 - 4200444/555
Tamil Nadu.

The Apollo Clinic, # 19-9-29/2A,

Andhra (0877) 2255 277 / 377 /
17 Tirupati Tirupati Tiruchanur Road, Sankarambadi Circle, theapollotirupati@gmail.com;
Pradesh 477
Tirupati – 517 501.

The Apollo Clinic, 2nd Floor, Tej kumar lucknow@theapolloclinic.com

18 Lucknow Lucknow Uttar Pradesh 0522 - 4917777
Plaza, 75, Hazratganj, Lucknow – 226001. ritesh@apolloclinic.in

The Apollo Clinic, 142- A, Hanuman

19 Gorakhpur Gorakhpur Uttar Pradesh Mandir Road, Betiahata, Gorakhpur – gorakhpur@theapolloclinic.com 0551 – 233 5800 / 5801
273 001.

The Apollo Clinic Durgapur, Junction

0343 254-8111,(2) 0343
20 Durgapur Durgapur West Bengal mall, Ground Floor, City Centre, durgapur@theapolloclinic.com
254-8199
Durgapur - 713216.

The Apollo Clinic, DC Block, Office Tower,

21 Salt Lake- Calcutta Kolkata West Bengal Sector 1, City Centre, Salt Lake, Kolkata saltlake@theapolloclinic.com 033 - 2358 1021 – 23
700 064, West Bengal

The Apollo Clinic, P 72, Prince Anwar

033 – 40212525 - 55,
Prince Anwar Shah Road, Opp.: South City Mall, CIT
22 Kolkata West Bengal pashahroad@theapolloclinic.com 24224446 /
Shah Scheme – 114 B, Kolkata – 700 045. West
Fax: 033- 4021 2536.
Bengal

doonapollo@rocketmail.com;dehra
The Apollo Clinic, Melody Cottage,
23 Dehradun Dehradun Uttaranchal dunapollo@gmail.com;dehradun@t 91-9219044012
8/4-1, Ballupur Road, Dehradun
heapolloclinic.com

Apollo Clinic, Main Road, Lohia Nagar,

24 Patna Patna Bihar patna.theapolloclinic@gmail.com 0612 234 1014
Patna, Bihar 800020

Apollo Clinic, 168 G T Road (South), howrahclinic@gmail.com, (033) 2642 7018/

25 Howrah Kolkata West Bengal
Shibpur, Howrah 711 102,West Bengal howrah@theapolloclinic.com 7019/ 7020
 Empanelled NM Hospital Branches for Health checkups

Health 360, Marine Lines

NM Medical, Chowpatty
Darya Nagar House
Mehta House
Next to ICICI Bank
36, Pandita Ramabai Road,
Maharshi Karve Road (Queens Road)
Chowpatty,
East Marine Lines
Mumbai - 400 007
Mumbai – 400 002
Tel. No. – 4342 5555
Tel. No. – 4342 9999
Contact Person: Ms Sharmila / Ms Tasneem
Contact Person: Ms Yamini / Deepa
(Open from Monday – Saturday)
(Open from Monday – Saturday)

NM Medical, Khar (West) NM Medical, Mulund (West)

Summerville Apartments 8th Floor, Corporate Centre
Junction of 14th & 33rd Road, Nirmal Lifestyles Mall
Off Linking Road, LBS Road,
Khar (West) Mulund (West),
Mumbai - 400 052 Mumbai - 400 080
Tel. No. – 4342 8888 Tel. No. – 4342 7777
Contact Person: Ms Sherry / Ms Anne Contact Person: Ms Meenakshi / Ms Anupama
(Open from Monday – Saturday) (Open from Tuesday – Sunday)

NM Medical, Borivali (West)

NM Medical Centre, Malad (West)
Swastik Bldg., 18/6,
Ground Floor
R C Patel Road,
Sej Plaza, Marve Road,
Chandavarkar Cr. Rd. no. 2,
Next to Nutan Vidya Mandir School,
Next to ICICI Bank
Malad (West)
Borivali (West)
Mumbai :400 064
Mumbai – 400 092
Tel: 28063333
Tel. No. – 4342 4444
Contact Person : Ms.Neeta / Ms. Namita
Contact Person: Ms.Sneha / Ms. Pushpa
(Open from Monday to Sunday)
(Open From Monday - Sunday)

NM Medical, Bangalore
NM Medical Centre , Parel (West)
Tower A, Corporate Block,
Parel Premises, Ground floor
Diamond District
Opp.Motilal oswal tower,
Airport Road
Next to Parel ST bus depot
Bangalore – 560 080
Junction of Sayani & Gokhale rd south
Tel: 4046 6464
Parel (W) Mumbai : 400025, Tel: 49662222
(Open from Monday – Saturday)

NM Medical, Pune

Fortaleza, F Annex
Above ING Vysya Bank, Kalyani Nagar,
Pune: 411014, Tel: 020 2660 0505
(Open from Monday – Sunday)
 Empanelled Fortis Hospital List

Delhi NCR Location Punjab Location Bangalore Location

Fortis-Escorts Hospital Fortis Escorts Hospital, Amritsar Fortis Marathalli Super Speciality
Neelam Bata Road, Faridabad-121001 Majitha - Verka Bypass Road, clinic
Amritsar-143004 Marathalli Banglore
Fortis-Escorts Heart Institute &
Research Centre Ltd. Fortis Hospital FORTIS HOSPITALS,
Okhla Road, New Delhi-110025 Sector-62, Phase-VIII SESHADRIPURAM
SAS Nagar, Mohali-160062 Address;No 65 1st Main,
Fortis Ft. Lt. Rajan Dhall Hospital Seshadripuram,
Sector-B, Pocket-1, Aruna Asaf Ali Fortis Hospital Bangalore-560020
Road, Chandigarh Ludhiana Road,
Vasant Kunj, New Delhi-110070 Ludhianan , 6 Kms away from FORTIS HEALTH MANAGEMENT LTD
samralachowk , No.23 80 feet Road,
FORTIS HOSPITAL Ludhiana – Punjab
A Block, Shalimar Bagh Guru Krupa Layout
Near Kela Godown Mumbai Location 2nd stage Nagarbhavi
New Delhi-110088 Bangalore-560072

Fortis La Femme Hospital FORTIS HIRANANDANI HOSPITAL FORTIS HEALTHCARE - BG ROAD

S-549, Greater Kailash - II, Mini Seashore Road, Sector-10A, 154/9, Bannerghatta Road,
New Delhi-110048. Vashi, Navi Mumbai-400703 Opp. IIM-B, Bangalore - 560 076.

Fortis Hospital SL Raheja ( A Fortis Associate) FORTIS HOSPITALS

B-22, Sector-62, Noida - 201301 Address: Raheja Rugnalaya Marg, No 14, Cunningham Road
Mahim (W), Mumbai-400016 Bangalore -560052
Kolkata Location Phone: (080) 4199-
FORTIS HOSPITALS 4444/9663367253
FORTIS HOSPITALS Bail Bazaar, Shill Road,
111A, Rashbehari Avenue, Kalyan West FORTIS HOSPITALS
Mumbai: 421301 No.111, west of chord road
Kolkota - 700029
opp Rajajinagar,
1st block Junction
FORTIS HOSPITALS Bangalore-560086
Phone: (080)2300-4444/9663367253
Mulund Goregaon Link Road,
Mumbai 400078
 Empanelled Fortis Hospital List

Kolkata Location Jaipur Location Bangalore Location

Fortis Hospitals Fortis-Escorts Hospital Fortis Malar Hospital

Jawahar Lal Nehru Marg, Malviya 52, first Main Road,
730, Anandpur Nagar, Gandhi Nagar, Adyar
Near Kolkata International School Jaipur-302107 Chennai-600020.
EM By-pass Road|
Kolkata – 107

Fortis Medical Centre.

2/7 Sarat Bose Road,
Kolkata - 700020