Reliance Power Limited
Pre-Employment Medical Examination
Prospective employee should fill Section 1 to 4. The Examination Medical Officer will fill Section 5 & 6. Confidentiality of information will be maintained.
NAME OF THE HUMAN RESOURCE EXECUTIVE – Ms. Madhura Gupte
1. PERSONAL DETAILS :
Name __________________________________________________________________
(Surname) (Other name)
Address: ________________________________________________________________
Birth Place : ______________ Date of Birth _____________ Religion_____________
Intended Occupation: (Desk Job / Field Job). If Field Job, Nature of Work – _______________
Marital Status ____________ Sex ____________
2. FAMILY HISTORY: Has anyone of your family suffered from Cancer, Diabetes, Hypertension
Tuberculosis, Epilepsy, Mental or Nervous disease? _____
IF LIVING IF DEAD
AGE HEALTH (GOOD,BAD, FAIR) AGE AT DEATH CAUSE OF DEATH
FATHER
MOTHER
BROTHERS (NO.)
SISTERS (NO.)
HUSBAND/WIFE
CHILDREN (NO.)
3. PERSONAL HISTORY
Are you in good health and capable of full work ___________________________
Types of previous occupation? ________________________________________
Have you ever suffered from an occupational disease or injury ?
Have you ever been discharged or rejected on medical grounds ?
Date of last Vaccination ___________________________
Have you ever suffered from any of the following: (Answer Yes or No. If yes give details)
Rheumatic Fever: Yes/No ________________ Any other illness: Yes/No._____
Heart trouble: Yes/No.________________ Jaundices: Yes/No.______
Stomach or other digestive disorder: Yes/No. Diabetes : Yes/No.________
Asthma: Yes/No.______ Pleurisy: Yes/No. Fits,Fainting or dizziness: Yes/No.______
Pulm T.B.: Yes/No._____ Chr.Bronchitis : Yes/No._ Nervous/Mental disease of any kind : 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 or : Yes/No.______
Sinusitis : Yes/No.________ Ear trouble : Yes/No.______
Operation or injuries : Yes/No._________ 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 unwillingly 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: ______________________________
5. RESULTS OF PHYSICAL EXAMINATION:
1. General Appearance _________________________ Skin _____________
2. Throat_________ Tonsils ___________ Thyroid ________ Glands _____
3. Ears_______ Hearing E.G. Whisper. 20 ft.___________ Nose _______
Affix your passport
size photograph
4. Teeth & Gums _________________ Tongue ______________
5. Vision Distant : R.E. ____ L.E. ______ Corrected R.E._____ L.E._____
Near : R.E. ______ L.E. ______ Corrected R.E._____ L.E._____
6. Height ____________ Chest Exp. _____________ Insp.__________ Photograph to be duly attested
by the examining doctor
Weight____________ Girth at Navel_____________________________
7. Heart-Sounds ________________ Mummurs __________________
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 _________________ Pupillary Reaction __________________
Plantars ______________ Knee Jerks ____________ Rhomberg’s ____________
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 _________________
6. COMMENTS AND RECOMMENDATIONS:
