Serial No: ...........................................................
|
Last Name: ....................................................... Height: ............................................. cm DOB: ................................................... Passport No: ........................................... Position Applied for: ........................................... History of any significant past illnesses including:
Allergy: ................................................... |
First Name: ....................................................... Weight: ............................................. kg Status: ........................................... Nationality: ........................................... Place of Issue: ....................................... Recruiting Agency: ....................................... |
I hereby permit the ....................................... and the undersigned physician to furnish such information the company pertaining to my health status and other pertinent medical findings and to release/refer these items freely and at legal hours for employment benefits and claims.
Signature of Examinee: .......................................
MEDICAL REPORT
1. MEDICAL INVESTIGATIONS
| TYPE OF MEDICAL EXAMINATIONS | RESULTS |
|---|---|
|
EYE R: .................... L: .................... EAR R: .................... L: .................... NOSE MOUTH |
...................................... |
| RESPIRATORY SYSTEM | ...................................... |
| GASTRO-INTESTINAL TRACT | ...................................... |
| VENEREAL DISEASES | ...................................... |
| CLINICAL | ...................................... |
2. LABORATORY INVESTIGATIONS
| TYPE OF LAB INVESTIGATIONS | RESULTS |
|---|---|
| URINE | ...................................... |
| BLOOD | ...................................... |
| SEROLOGY | ...................................... |
| ELISA | ...................................... |
| PREGNANCY TEST | ...................................... |
Notes about medical and laboratory investigations:
...................................................................................
...................................................................................
Dear Sir,
Mentioned above is the medical report for Mr. / Mrs. ...................................................
He / She is fit for the above mentioned job.
Unit:
Chief Physician
Stamp
Name: .......................................
Signature: .......................................