Documente Academic
Documente Profesional
Documente Cultură
1. PERSONAL DETAILS :
Name……………………………………………………………………………………………………………………………………………….
(Surname) (Other Names)
Address: ……………………………………………………………………………………………………………………………………………
Birth Place: ……………………………….Date of Birth: …………………………………… Religion: …………………..……….
Intended Occupation: ……………………..Marital Status: …………………..…………Sex: ………………....................
2. FAMILY HISTORY Has anyone of your family suffered from Cancer, Diabetes,
Tuberculosis, Epilepsy, Mental or Nervous disease? ______________
IF LIVING IF DEAD
AGE HEALTH (GOOD, BAD, FAIR) AGE AT DEATH CAUSE OF DEATH
FATHER
MOTHER
BROTHER (NO.)
SISTER (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 illnesses: Yes/No. ………………….……………………….....
Heart trouble: Yes/No ……………………………………….Jaundice: 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………………………………… Venereal 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. RESULT OF PHYSICAL EXAMINATION :
1. General Appearance…………………………………………………….Skin…..………………………………………………………….
2. Throat………………….…….….Tonsils………………….……Thyroid…………………..………Glands……………………………
3. Ears……………..………… Hearing E.G. Whisper 2 Meter……………………………..Nose ……………………………….…
4. Teeth & Gums………………………………………………………….….Tongue…………………………………..……………………..
5. Vision Distant: R.E.…………………………….L.E…………………….Corrected R.E………………..……L.E. ………………....
(Please provide the exact values)
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…………………………………………………………………………………………………………………………………………………..
12. Nervous System………………………………………………………Pupillary Reaction……………………………….…………….
Plantars……………………….………………Knee Jerks ………………………………..Romberg…………………………………….
Urine: Sp. Gr. ………………Reaction …………………………………….…Albumin ………………..Sugar………….………….
Microscopic (If required)…………………………………………………………………………………………………………………….
Blood Haemoglobin (g%)………………Blood Sugar (FBS/RBS)……..……….Blood Group…………………….
(Please provide the exact values) (Please provide the exact values)
13. Chest X-ray/Screening…………………………………………………………………………………………………………………………
14. E.C.G: ……………………………………………………………………………………………..………………………………………………..
15. Other Investigations, if any: ………………..………………………………………………………………………………………………
16. Medically Fit: Yes/ No ______
Apollo clinic, 66 A/2, New Rohtak Road, Karol Rachna Pilani-FO Manager:
Karol bagh, Bagh, New Delhi cc.kbh@apollospectra.com:88
2 Delhi Delhi NCR
New Delhi 60246241
(Apollo Spectra)
5D/ 8A, NIT-5,Railway station Mr.Ram Awadh Singh Mo:
Road,Near Neelam Chowk,Faridabad 7309134442
– 121001. Phone:0129-4150038
The Apollo Email:
3 Faridabad Delhi NCR
clinic, Faridabad fo.faridabad@apolloclinic.com;
ramawadh.singh@apolloclinic.
com.
54, First Floor, 12th Main Road, HSR Center Manager: Manjunath V
Layout - Mo: 9844701222
Apollo clinic, Phone: (080) 2572 4235 - 8
7 Bangalore Karnataka
HSR Layout Email: hsr@apolloclinic.com;
manjunath.v@apolloclinic.com
2012, 1st Floor, 100 Feet Road, HAL Center Manager: Ms.Punita
2nd stage, Indira Nagar Singh - Mo: 8197985985
Phone: (080) 2521 4614/15
Apollo clinic,
8 Bangalore Karnataka Email:
Indiranagar
indiranagar@apolloclinic.com;
punita.singh@apolloclinic.com
Mann Complex, Anand Mahal Road, Ms. Sohil Mehsania- CM, Mr.
Adajan, Surat – 395 009 Sonal Tank- Accounts
Manager;
Mo 91 9979858877 / 91
9409077009
Phone: 0261 – 279 0202 / 279
The Apollo
4 Clinic, Surat Gujarat 5031;
Surat(Network) Email:
adajan@theapolloclinic.com,
apolloclinicsurat@gmail.com;
The Apollo Clinic, The Emerald, Plot No. Phone: 022 - 2788 1322 -
195/B, Sector–12 Besides Neel Siddhi 1325;
Apollo clinic, Towers, Vashi, Navi Mumbai – 400 703. Email:
9 Mumbai Maharashtra
Vashi (Network) vashi@theapolloclinic.com
2nd floor, Above D mart, Highland Park, Ms. Shilu Cherian Mo:
Kolshet Road, Off GB Road, Thane (W) 8691085589
400607 Phone:022-25890200/300,
The Apollo 022-25840400
11 Clinic, Thane GB Mumbai Maharashtra Email:
(Network) thanegbroad@theapolloclinic.
com
The Apollo Clinic, 1st Floor, “A” Wing, Mrs. Poornima- Head
Ambika Apartments, Mahakali Caves Operationds- Mo: 91
Road, Andheri-East, MUMBAI-400 093 9324357797
The Apollo Phone:022 -2826 2741 / 2742
12 Clinic, Andheri Mumbai Maharashtra ;28263734/35
East (Network) Email:
andherieast@theapolloclinic.c
om
SCO 170-171, Madhya Marg, Sector 9C, Dr. Canny - Mo: 9508008117
Chandigarh 160 017 Phone: 0172-4006060
Email:
The Apollo
Chandigarh/ hr.apollo.chd@gmail.com;cha
15 Clinic,Chandigar Punjab
Mohali ndigarh@theapolloclinic.com
h (Network)
Narayana Vaishno
Vaishno Devi, Jammu &
18 Devi Specialty
Jammu Kashmir
Hospitals Pvt. Ltd.
NM Medical, Indira
21 Bangalore Karnataka
nagar, Banglore
Clinic Name/
Sl City State Clinic Address Clinic Contact
Location
258/A, Bommasandra Industrial Health check team : 080-71
Area, Anekal Taluk, Bangalore - 222 222;9980512431;
560 099 Email: ehp@hrudayalaya.com
Mazumdar Shaw
Medical
22 Centre,Narayana Bangalore Karnataka
Hrudayalaya Ltd.,
Hosur Road
Manipal Hospital
28 Bangalore Karnataka
Whitefield
NM Medical centre,
37 Mumbai Maharashtra
Mulund
NM Medical centre,
41 Mumbai Maharashtra
Andheri West
NM Medical centre,
42 Mumbai Maharashtra
Borivali West
NM Medical centre,
43 Mumbai Maharashtra
Khar West
NM Medical centre,
45 Mumbai Maharashtra
Parel West
Amri Hospitals,
49 Bhubaneshwar, Bhubaneswar Orissa
Orissa
AMRI Hospitals
58 Kolkata West Bengal
Southern Avenue
Amri-Salt Lake, JC -16 & 17, Salt Contact: Gaurab Maiti +91-
Lake City, Kolkata - 700 098 3366147700; 8420223302/
9831698254
AMRI Hospitals Salt
59 Kolkata West Bengal
Lake
Clinic Name/
Sl City State Clinic Address Clinic Contact
Location
127 Mukundapur, E.M. Bypass, Sanjukta Paul: 9230095215;
Kolkata: 700099 Ph:+91 33 66520000,
Email:
contactus@medicahospitals.in
;
sanjukta.paul@medicasynergi
Medica e.in;
60 Superspeciality Kolkata West Bengal Corporate Desk for Medica
Hospital Kolkata to facilitate
appointments etc –
09230011834