Professional Documents
Culture Documents
Fitness Form & Hospital List
Fitness Form & Hospital List
1 PERSONAL DETAILS :
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
FATHER
MOTHER
BROTHER (NO.)
SISTER (NO.)
HUSBAND/WIFE
CHILDREN (NO.)
Yes No
3 PERSONAL HISTORY :
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 any skin 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, otitis etc.)
Any major operation or injury Any other illnesses
Do you have any 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.
Y N
Squint
Any other eye disease if yes pl. give details ____________________________________________
Remarks: _______________________________________________________________________________________________
The Apollo clinic, 50 -81 -1/2, Plot 5, Sheethammapeta, Phone: (0891) 258 5511 - 2, 2548818
Visakhapatnam Andhra Pradesh
1 Vishakapatnam Visakhapatnam Email: vizag@apolloclinic.com;
rama.devi@apolloclinic.com
Apollo clinic, Karol bagh, New 66 A/2, New Rohtak Road, Karol Bagh, Rachna Pilani-FO Manager:
Delhi Delhi NCR
2 Delhi (Apollo Spectra) New Delhi cc.kbh@apollospectra.com:8860246241
Apollo clinc, Chembur (Apollo Sunder Baug, Ujagar Compound, Opp. Deonar Bus Ms. Pavani Keta: 8655531669
15 Mumbai Maharashtra
Spectra) Depot Main Gate, Mumbai - 400 088 cc.cbr@apollospectra.com
Apollo Clinic,1, Cosmic Enclave,Opposite SBI Ms. Beena Anand; Mo 91 98370 31808;
The Apollo Clinic,
Bank ( Sama Branch),Near GIPCL Circle, Phone: 0265-2780040, 2780030
5 Vadodara (Network) Vadodara Gujarat
Sama,Vadodara-390008, Email: vadodara@theapolloclinic.com
Rasheed(CM); 91-9765550413 ;
Plot No 50, Jai Vishwa Bharati Colony,Opp
The Apollo Clinic, Phone: 0240 2354304, 2354306,
Sapna Super Market, Chetak Ghoda Chowk,
8 Aurangabad (Network) Aurangabad Maharashtra Email: aurangabad@theapolloclinic.com;
Aurangabad 431005
nacgroup@nac.co.in
The Apollo Clinic, Z-5, Z Shopping Centre, Sandeep Talwar Mo: 9869240803
The Apollo Clinic,
Flower Valley, Off.Eastern Express Highway, Phone:(022) 2547 0011 / 2547 5055
10 Thane (Network) Mumbai Maharashtra
Khopat, Thane (W), Maharashtra.400601 Email: thane@theapolloclinic.com
Shop no.12 & 13, Building No 41, Jumana Khambatwala Mo: 9029045395 /7506301194
The Apollo Clinic, Swwapnashilp CHS Near Tilak Nagar Police Phone:022 - 25290884/85
Mumbai Maharashtra
13 Chembur (Network) Station, Opp. Lokmanya Tilak High School, Email: jumana.khambatwala@oneworldimpex.com,
Mumbai, Maharashtra 400089 chembur@theapolloclinic.com
Apollo Clinic, New 33-42, Ground Floor, The Galleria - DLF Mr.Sudipto; Mo: 8585073755
Kolkata, Plot no: BG-8, Action Area : IB, Phone: 033-4036 5500
23 town (Network) Kolkata West Bengal
Rajarhat, Kolkata - 7000156 Email: newtown@theapolloclinic.com
Apollo Clinic, PA Shah The Apollo Clinic,P 72,Prince Anwar Shah Mr.Atanu Mo: 9830196659
Road,Opp: South City Mall, CIT Scheme - 114 Phone: 033 - 40212525 - 55, 24224446 / Fax : 033- 4021
24 road (Network) Kolkata West Bengal
B,Kolkata - 700 045. West Bengal 2536 pashahroad@theapolloclinic.com
Nidhi
Ph: 9810600546; 011 4277 6222
Fortis Flt. Lt. Rajan Email:phc.vk@fortishealthcare.com /
Sec-B, Pocket-1, Aruna Asaf Ali Marg, Vasant
Dhall Hospital, New Delhi Delhi NCR jyotsna.popli@fortishealthcare.com
2 Kunj, New Delhi - 110070.
Delhi Ph2: 98106-00546; 011 4277 6222
phc.vk@fortishealthcare.com ;himanshu.batra@fortishe
althcare.com
Ravish Mathur,
Fortis Hospital - Ph:98101-32590; 011 4530 2222
A-Block, Near Kela Godown, Shalimar Bagh,
Shalimar Bagh, New Delhi Delhi NCR Email: ravish.mathur@fortishealthcare.com
3 New Delhi - 110088.
Delhi Ph2: 98108 - 96442 ;011 4530 2222
Email2: phc.sb@fortishealthcare.com
Manmeet
Ph: 9971494646; 0129 246 6000
Fortis Hospital, Fortis Escorts Hospital, Neelam Bata Road, Email: manmeet.kaur1@fortishealthcare.com,
Faridabad Delhi NCR
4 Faridabad Faridabad - 121001, Haryana. manvendra.gour@fortishealthcare.com
Ph2: 98715-39191,0129 246 6000
phc.fbd@fortishealthcare.com
Sidharth Verma
Fortis Memorial Ph: 98997-65298; 0124 4962200
,Sector 44, Opposite HUDA City Centre Metro
Research Institute, Gurgaon Delhi NCR Email: sidharth.verma@fortishealthcare.com
5 Station, Gurgaon - 122002, Haryana.
Gurgaon Ph2: 8376908992 /0124 4962200 ; 0124 496 2200
Email2: fmri.health4u@fortishealthcare.com
Shalini Arora
Ph: 9650268883; 0120 240 0222
Fortis Hospital - Noida Noida Delhi NCR B-22, Sector-62, Noida - 201301 Email: shalini.arora2@fortishealthcare.com
6
Ph2: 96502-68883 ; 0120 430 0222
Email2: phc.noida@fortishealthcare.com
Ganesh
Fortis Hospital, 154/9, Bannerghatta Road, Opposite IIM-B, Ph:9945300733/ 080-66214031
Bangalore Karnataka
7 Bannerghatta Road Bengaluru - 560076, Karnataka. Email: ganesh.nagraj@fortishealthcare.com
Phone2: 080-66214113/080-66214195; 080-66214101
Farooq Azam
Fortis Hospital, Ph: 9845868983, 080-41994444
14, Cunningham Road, Bangalore - 560052,
Cunningham Bangalore Karnataka Email: farooq.azamp@fortishealthcare.com
8 Karnataka.
Road,Bangalore Ph2: 080-41994444/4452/4453;
080-41994444/22261037
Shreekar Bharadwaj
Fortis Hospital, 23, 80ft Road, Guru Krupa Layout, Nagarbhavi Ph: 7760968343, 080-23014444
Bangalore Karnataka
9 Nagarbhavi 2nd Stage, Bengaluru - 560072, Karnataka. Email: shreekar.bharadwaj@fortishealthcare.com
Ph2: 080-23014444; 080-23014444
Prasad tawde
Shill Road, Bail Bazaar, Kalyan, Mumbai, Ph: 8898814962
Fortis hospital, Kalyan Mumbai Maharashtra
11 Maharashtra 421301 Email: prasad.tawade@fortishealthcare.com
Ph2: 9552084031; 0251 6694198 ; 0251 669 4100
Priya Sawant
Mulund Goregaon Link Road, Mulund-West, Phone: 8108800259/ 022 49254894
Fortis hospital, Mulund Mumbai Maharashtra
12 Mumbai, Maharashtra 400078 Email:priya.sawant@fortishealthcare.com
022-67994350-51; 022-41114111
Clinic Name/
SL City State Clinic Address Clinic Contact
Location
Mr. Nitin Kamaria: 9819647775;
Phone: +912243654365;
Hiranandani Fortis Mini Sea Shore Road, Sector 10, Vashi, Navi Email: nitin.kamaria@fortishealthcare.com
Mumbai Maharashtra Email2: ehc.vashi@fortishealthacre.com /
13 Hospital, Vashi Mumbai, Maharashtra 400703 backoffice.vashi@fortishealthcare.com
Phone2: 022-39199300/ 9867441620/ 7666160147/
022-39199100
Manbir Singh
Fortis Escorts Hospital, Majitha-Verka Bypass Road, Amritsar - Ph: 9592944684; 1833012222
Amritsar Punjab Email: manbir.singh@fortishealthcare.com
14 Amritsar 143004, Punjab. Ph2: 0183-2573900 ; 0183 301 2222
Email2: phc.fehasr@fortishealthcare.com
Anmol kaushik
Ph: 9988697207 0172 502 1222
Chandigarh/ Sector 62, Phase - VIII, Mohali - 160062, Email: anmol.kaushik@fortishealthcare.com
Fortis Hospital, Mohali, Punjab
15 Mohali Punjab Ph2: 9815303463; 01725021222
;0172-469 2222
Email2: upasna.arora@fortishealthcare.com
Deepak Bakshi
Fortis Hospital, 6kms from Samrala Chowk, Chandigarh Road, Ph: 7508972516; 0161-5222333
Ludhiana Punjab Email: deepak.bakshi@fortishealthcare.com
16 Ludhiana Ludhiana, Punjab. Ph2: 0161 522 2333 ;0161 522 2333
Email2: phc.ldh@fortishealthcare.com
Rajesh Choudhary
Fortis Escorts Hospital, Jawahar Lal Nehru Marg, Malviya Nagar, Jaipur Ph: 9799496906 ; 0141-2547000
Jaipur Rajasthan Email: rajesh.choudhary@fortishealthcare.com
17 Jaipur - 302017, Rajasthan. Ph2: 9799496906 ; 0141 254 7000 ; 0141 254 7000
Email2: contactus.jaipur@fortishealthcare.com
Clinic Name/
SL City State Clinic Address Clinic Contact
Location
Narayana
Near Tolaram Bafna Civil Hospital Campus, Sukalyan : 0361 2680321; 8811077610;
Superspeciality Guwahati Assam
4 Amingaon, Guwahati - 781031 Email: sukalyan.sarma@nhhospitals.org
Hospital
Clinic Name/
SL City State Clinic Address Clinic Contact
Location
Paras HMRI Hospital, Phone: 0612 7107700;
Patna Bihar NH 30, Bailey Road, Patna, Bihar 800014
5 Patna Email: corporatepatna@parashospitals.com
NH MMI Narayana Lalpur, Dhamtari Road, Raipur, Chhattisgarh - Sujith: 0771-241 9001, 8819000018,
Raipur Chattisgarh
7 Multispeciality Hospital 492 001 Email: sujit.khare@nhhospitals.org
CH Baktawar Singh Road, Sector 38, Near Rajiv Vikas goel:70421 - 94674;
Medanta Hospital,
Gurgaon Delhi NCR Chowk, Islampur Colony, Sector 38, Gurgaon, Phone: 0124 414 1414;
9 Gurgaon
Haryana 122001 Email: Vikas.goel@medanta.org
Narayana Opp. Rakhiyal Police Station, Rakhiyal Cross Mr. Sunil : 079-7122 2222; 8980008130;
Ahmedabad Gujarat
12 Multispeciality Hospital Road, Ahmedabad - 380 023 Email:sunil.soni@nhhospitals.org
Plot Health Centre, Ward 10-B C, Nr. YMCA, Contact No: 02836 - 619600
Sterling hospital,
Gandhidham Gujarat Opp. IFFCO Colony, Gandhidham Gujarat , Mr.Maunish Dave - 9924015754
14 Gandhidham
370201 Maunish.Dave@sterlinghospitals.com
Shrei Pramukh swami Mr Ankit Sharma: 9979100022; Phone: 0261 322 2100 /
Shri pramukh swami maharaj marg, Adajan
BAPS Pramukh swami Surat Gujarat 2200 / 2222
16 char rasta, Adajan, Surat - 395009
hospital, Surat Email: mktbapshospital@gmail.com
Brahmananda Narayana Tamolia, Near Pardih Chowk, NH 33, Ranjay : 0657-6600 500; 9709999792;
Jamshedpur Jharkhand
22 Multispeciality Hospital Jamshedpur - 831 012 Email: ranjay.singh@nhhospitals.org
Medanta Abdur
Phone:0651 712 3100;
razzaque ansari
Ranchi Jharkhand PO- Irba, Ormanjhi, Ranchi, Jharkhand- 835217 Indrajeet Banerjee: 9955024705; 9883338350;
23 memorial weavers
Email:Indrajeet.Banerjee@Medanta.org
hospital,
Medica Superspeciality
Phone:0651 660 6000;
Hospital (Bhagwan Bariatu Road, In front of P.H.E.D Colony, Near
Ranchi Jharkhand Harsh Daruka : 7033093311;
24 Mahavir Medica Booty More, Ranchi, Jharkhand 834009
Email: harsh.daruka@medicasynergie.in
Superspecialty Hospital)
NM Medical, Indira Tower A, Corporate Block, Diamond District Ms. Meenakshi/ Ms. Sarita
Bangalore Karnataka
25 nagar, Banglore Airport Road Bangalore - 560 080(Indira nagar) Tel. No. - 4046 6464
Mazumdar Shaw
Medical
258/A, Bommasandra Industrial Area, Anekal Health check team : 080-71 222 222;9980512431;
Centre,Narayana Bangalore Karnataka
26 Taluk, Bangalore - 560 099 Email: ehp@hrudayalaya.com
Hrudayalaya Ltd., Hosur
Road
Narayana
Multispeciality Clinic, No.43/A, 1st Floor, Bda Complex, HSR Layout Melvin : 9538076688;
Bangalore Karnataka
27 HSR , Narayana Sector 6, Bangalore - 560034 Email:melvin.kumar@nhhospitals.org
Hrudayalaya Ltd.
Narayana
Plot No : 3&4, Sadaramangala Industrial Area,
Multispeciality Hospital, Sarvjeet : 080-7111 2555; 959110699;
Bangalore Karnataka Opp to ITPL Main Gate, Whitefield, Bangalore -
28 Whitefield, Narayana Email: sarvjeet.kumar@nhhospitals.org
560 066
Hrudayalaya Ltd.
Narayana
Multispeciality Basant Health Centre No. 1, 18th Main, Sector Melvin : 080- 7111 2300, 9538076688;
Bangalore Karnataka
29 Hospital,HSR , Narayana 3, HSR Layout, Bangalore - 560 102 Email:melvin.kumar@nhhospitals.org
Hrudayalaya Ltd.
No 98, Rusthom Bhag, Airport road, Mr. Amit Mohanty; Mo: 8088788678;
Manipal Hospital Bangalore Karnataka
31 Bangalore, Karnataka- 560 017 Phone: 080 - 2502 3221 / 4660 / 4661
No 71, 11th Main, Malleswaram, Opp the Mr. Harish Seenappa; Mo: 98866 59233;
Manipal North Side
Bangalore Karnataka Malleshwaram Station, Bangalore, Karnataka- Phone: 080 - 2346 0468 / 0469 / 0470
33 Hospital
560 003 Email: harish.seenappa@manipalhospitals.com
Clinic Name/
SL City State Clinic Address Clinic Contact
Location
Mr. Praveen Kulkar; Mo: 96869 99512;
KMC Hospitals, Manipal Ambedkar Circle, Mangalore, Karnataka, 575
Mangalore Karnataka Phone: 0824- 244 4590
34 group of hospitals. 001
Email: praveen.kurkal@manipalhospitals.com
Sahyadri Narayana
RajaSingh : 08182-221 588; 8884416908;
Multispeciality Hospital, Shimoga Karnataka Harakere, N T Road, Shimoga - 577 202
36 Email: rajasingh.sv@nhhospitals.org
Shimoga
Medanta Superspecialty Scheme number- 54, Vijaynagar square, AB Rahul Gupta: 9910072295
Indore Madhya Pradesh
41 hospital, Indore road, Indore, MP Phone:0731 474 7000: 07314747000;
Reliance Corporate
Park- Medical Center- Reliance Corporate Park- Medical Center- Near Dr. Mohan Aterkar ; Dr. Vivek Malpure
Near gate B, Ghansoli, Mumbai Maharashtra gate B, Ghansoli, Thane Belapur Road, Navi RCP- 022 44776694
45
Thane Belapur Road, Mumbai- 400701. Email: mohan.aterkar@ril.com; vivek.malpure@ril.com
Navi Mumbai- 400701.
Mr sunil muley
Rainbow hospital, 282, Central bazar road, Ramdaspeth, Nagpur-
Nagpur Maharashtra Phone: 0712-6636666
52 Nagpur 440010.
Email:sunilmuley.19@gmail.com
Narayana Sec-28, Kumbha Marg, Prathap Nagar, Jaipur - Nitesh: 0141-5192 939, 0141 71 22 222; 9694096099;
Jaipur Rajasthan
56 Multispeciality Hospital 302 033 Email: nitesh.tiwari@nhhospitals.org
MR.SASIDHAR; MO:9515116718;
Yashoda hospital, Email:sasidhar.gangavarapu@yashoda.in;
Hyderabad Telangana Raj bhavan road, Somajiguda
60 Somajiguda saikrishna.avinash@yashoda.in;
nagesh@yashodamail.com
Amri-Salt Lake, JC -16 & 17, Salt Lake City, Contact: Gaurab Maiti +91-3366147700; 8420223302/
AMRI Hospitals Salt Lake Kolkata West Bengal
65 Kolkata - 700 098 9831698254
Narayana Westbank Hospital, Andul Road, Podrah, Saumya: 033-2668 2668; 9874044410:
Kolkata West Bengal
67 Multispeciality Hospital Howrah - 711109 Email: soumya.ray@nhhospitals.org