Name :

Position Title : :

Age : Weight /Kg Height:(in Cm) :

Date of Birth : Sex :

Address :

Country of Origin: :

Country of Residence: :

Last Medical Exam Date:

Sl No. Yes

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

Key to convert from Inches to Centimeters : Multiply height in inches by 0.025 ( Inches x 0.025 = M)

MEDICAL QUESTIONNAIRE /DECLARATION TO BE COMPLETED BY THE CANDIDATE

Have you ever been refused employment of your health?Have you ever been denied insurance because of Health or Physical

reasons?

Have you ever been hospitalized for mental illness.

Abnormal Chest Xray

Any other Lung disease

Tumor of gastrointestinal tract or other digestive disease

Liver disease

Kidney Disease

Heart Murmurs

High Blood Pressure (uncontrolled)

Abnormal Electrocardiogram

Heart Disease of any kind

Key to convert from Pounds to Kilo Gram : Multiply weight in Pounds by 0.45 (lb x 0.45 = Kg)

Diabetes

Gall bladder disease

Cancer / Tumors

HIV Positive

Have you ever been unable to keep a job because of sensitivity to dust,

chemical etc.,?

BMI Calculation

Hepatatis A/B/C/

Shunt (e.g. pulmonary,cardiac)

Tuberculosis

Tumor of the Lung

Descritption No

E-mail

Contact Number

Heart Attack

Where and by Whom :

Have you ever had or been observed for any of the following , If yes give the details in the space below

1. Have you ever suffered a serious accident?

2. Have you ever suffered from any work related illness?

3. How many separate spells of sickness absences have you had in the past 12 months?

4. What is the total number of days you have been off work sick during the past 12 months?

Date of Birth

SIGNATURE OF THE CANDIDATE:___________________. DATE:______________________