Please paste Ref: Mr.

Abdul Gaffar, Services HR, RCP, Navi Mumbai

your
photograph
RELIANCE INDUSTRIES LIMITED
PRE-EMPLOYMENT MEDICAL EXAMINATION
(Prospective employee should fill in section 1 to 4, The Examining Medical Officer will fill in Section 5 & 6)
All details given below will be treated as confidential
1. PERSONAL DETAILS :

Name: ____________________________________________________________________________
(First) (Middle Name) (Surname)

Address:

Birth Place: ________________________ Date of Birth : ____________ Religion : _________________

Intended Occupation : _________________ Marital Status : ____________________ Gender : ____________

2. FAMILY HISTORY : Has anyone of your family suffered from Cancer, Diabetes, Tuberculosis, Epilepsy,
Mental or nervous disease ? _______________

IF LIVING IF DEAD
HEALTH
AGE AGE AT DEATH CAUSE OF DEATH
(GOOD,BAD, FAIR)
Father
Mother
Sister (nos.)
Brothers (nos)
Husband/ Wife
Children (nos.)

3. PERSONAL HISTORY :
Are you in good health and capable of full work :

Types of Previous Occupation?

Have you ever suffered from any occupational disease or
injury?
Have you ever been discharged or rejected on Medical
grounds
Date of last vaccination
Have you ever suffered any of the following ( Yes/No) Give Details if yes
Rheumatic Fever (Yes/No) Any Other illness (Yes/No)
Heart Trouble (Yes/No) Jaundice (Yes/No)
Stomach or other digestive disorder (Yes/No) Diabetes (Yes/No)
Asthma (Yes/No) Plurisy (Yes/No) Fits, faiting or dizziness (Yes/No)
Pulm. T.B. (Yes/No), Chi. Bronchitis
Nervous / Mental Disease of any kind (Yes/No)
(Yes/No)
Kidney Disease (Yes/No) Veneral Disease (Yes/No)
Malaria (Yes/No) Dermatitis or any skin disease (Yes/No)
Typhoid Fever (Yes/No) Any Allergy (Yes/No)
Sinusitis (Yes/No) Ear trouble (Yes/No)
Operation or Injuries Menstrual History L. M. P.
Do you have any physical handicap (Yes/No)

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 if
any of the said statements if proved wrong, the company may have unwittingly engaged my services and I shall therefore have
no claim against the company, if for these reasons, I am discharged from its service.

Date : ____________________________ Signature of Prospective Employee __________________________

RESULTS OF PHYSICAL EXAMINATION :

1. General Appearance__________________________________ Skin_______________________

2. Throat_______________ Tonsil ________________Thyroid_____________ Gland___________

3. Ears ____________ Hearing E.G. Whisper 20 ft.___________________ Nose_______________

4. Teeth & Gums _________________________________Tongue __________________________

5. Vision Distant :R. E. ________________ I.E. _____________ Corrected R.E._________I.E._____

Near R. E._____________ I.E. _____________ Corrected R. E. ________ I.E._____

Eye Disease ___________________________ Colour Vision _____________________________

6. Height _____________________________Chest Exp. __________________Insp.____________

Weight _____________________________ Girth at Navel ______________________________

7. Hearth-Sounds _______________________ Murmurs _________________________________

Arteries______________________________ Blood Pressure ___________________________

Pulse-Rate ___________________________ Character _______________________________

8. Lungs _________________________________________________________________________

9. Abdomen __________________________Liver ___________________Spleen _______________

10. Urinary and Genital Organs ________________________________________________________

Venereal Disease _________________________________________________________________

11. Special Conditions : Flat feet __________________________Varicose Veins_________________

Hernia________________ Deformities ___________________ Scars ______________________

Identification Marks ______________________________________________________________

12. Nervous System _______________________________Pupilary Reaction ___________________

Plantars ___________________ Knee Jerks _________________Rhomberg _________________

Urine: Sp. Gr.___________ Reaction _______________Albumin ____________Sugar __________

Microscopic (If required) ___________________________________________________________

Blood Haemoglobin _____________ Blood Sugar _______________Blood Group______________

13. Chest X- Ray / Screening ___________________________________________________________

14. E.C.G: __________________________________________________________________________

15. Other Investigation, if any __________________________________________________________

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COMMENTS AND RECOMMENDATIONS :

List of Tests to be conducted

1. General physical examination, including eyes and hearing examination.

2. Routine urine examination.

3. Urine examination for pregnancy test (in case of females).

4. C.B.C. and blood examination.

5. X – ray chest

6. E.C.G.

7. Blood Group

P.S. Kindly send the reports to the office of Dr R Rajesh, Medical Advisor at the below
Address.

Reliance Industries Limited,

2nd Floor, Maker Chambers - IV,
Nariman Point
Mumbai – 400 021