MEDICAL HISTORY

(To be filled in by candidate): Blood Group ___________

Name of Candidate : Address

Employee no :

Position Applied for Previous Occupation

Name of Private Physician :

Date of Birth Age Citizenship Place of Birth Date of Exam

SEX – MARITAL STATUS ( CHECK APPROPRIATE BOXES)

 Female  Single  Widowed  Divorced

 Male  Married  Separated

FAMILY HISTORY

LIVING DECEASED

Member of Family Age Health Age Cause of Death

Father

Mother

Disease Yes No Member of Family Disease Yes No Member of Family

Check Yes/No Check Yes/No

Tuberculosis

Cancer

Diabetes

Epilepsy

Comments :
 PAST HISTORY AND PRESENT ILLNESS (CHECK YES OR NO)

Have you ever Had Yes No Year Have you ever had Yes No Year
Eye Problem Depression
Ear Problem Diabetes
Migraine Headaches Cancer/Tumors
Coughing up Blood Anemia( Blood deficiency)
Tuberculosis ( T.B.) Sexually Transmitted Disease
Rheumatic Fever Epilepsy
Palpitations Malaria
High Blood Pressure Surgical Operations
Chest Pain Major Injury
Fainting-Dizzy Spells Thyroid Problems
Frequent Stomach upsets Food Intolerance
Ulcers/Acidity Hemorrhoids/Piles
Hepatitis/ Jaundice Prostate Problems
Allergy to any to any Medicine Arthritis
Kidney Stones Mental Disorders
Urine infections Skin Problems
Hernia
Weight Loss/Gain in last Year
Do You Yes No

Smoke Amount Per Day __________________

Drink Alcohol Amount Per Week__________________

Wear glasses or contact lenses Lens Power L_______ R _________

MENSTRUAL HISTORY ( For female candidates only)
Last Menstrual Period ___________________Duration ______________Regularity______________________

I hereby certify that the information stated in the form is correct to the best of my knowledge and belief.
If at any time the information turns out to be incorrect, I accept the liability of termination of my services

DATE :_________________

PLACE : ________________ SIGNATURE AND NAME