Scribd
Upload
531 views

Medical Self-Declaration Form: HCG/HR/MED/09/17/001

This document is a medical self-declaration form used by Health Careers Group to collect health information from job applicants and employees returning from sick leave. The two-page form asks about various medical conditions and disabilities. It also requests details on medications, medical surveillance, and fitness to return to work. Applicants must declare that the information provided is accurate and agree to inform the company of any health changes related to the questions. The form is reviewed and signed by both the applicant and Health Careers Group.

Uploaded by

laison issac
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
531 views

Medical Self-Declaration Form: HCG/HR/MED/09/17/001

This document is a medical self-declaration form used by Health Careers Group to collect health information from job applicants and employees returning from sick leave. The two-page form asks about various medical conditions and disabilities. It also requests details on medications, medical surveillance, and fitness to return to work. Applicants must declare that the information provided is accurate and agree to inform the company of any health changes related to the questions. The form is reviewed and signed by both the applicant and Health Careers Group.

Uploaded by

laison issac
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 2

HCG/HR/MED/09/17/001

Medical Self-Declaration Form

1. Do you suffer, or have you ever suffered from any of the following?

Health Issue Yes No Health Issue Yes No

Asthma or shortness of breath (Please Epilepsy or blackouts (Please list any


provide details below) details overleaf)

High / low blood pressure Stomach disorders

Any hearing disability Liver disorders

Diabetes (insulin dependent) Anaemia

Hernia Phobia (please specify)

Heart related problems Drug / alcohol addiction

Nervous disorders Allergies (please specify)

Back or disc related problem Mobility problems

Do you have any visual problems? (please Vibration white finger or any HAVs
provide details below) related condition

Tenisynovitis (joint problems)

If you are a married, female job seeker, please answer the given question

If Carrying If undergone abortion any time

1. Do you wear any spectacles or contact lenses? If yes, for what reason? (e.g. short sight, reading)
2. Are you currently taking any medication (prescribed or over the counter)?
Please give the name, mgs and how often you take it: _____________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
3. Are you registered disabled? YES/NO
4. If Yes, please provide details:
5. You will be subject to screening for presence of alcohol and / or drugs either for pre-employment or on a
random basis. Do you object to this? YES/NO
6. Are you currently under any medical surveillance? (e.g. lead, asbestos, back problems, etc.) If so, please give
full details YES/NO
Full name: ___________________________________________________________________________________
Date:
Signature:

Medical Self-Declaration Form Health Careers Group


Dated: October 2017 www.healthcareersgroup.in
Page 1 of 2
HCG/HR/MED/09/17/001

Medical Self-Declaration Form

Returning to work
(Applicable for staff resuming from long term Sick leave)

Is this form for a return to work, following an absence certificated by a doctor?


YES / NO

Have you obtained a certificate from your doctor stating you are fit to return to work?
YES / NO

Are there any restrictions to the work you are able to undertake? (please provide details )
YES / NO

Did you provide all supporting medical certificates to HR for record purpose?
YES / NO

Declaration:
I hereby declare that all information provided in this questionnaire are correct to the best of my knowledge and
belief. If any information given found to be incorrect later, company may take appropriate disciplinary action,
including termination of my employment based on the reason of furnishing false information against
employability criteria. In case any of my health conditions changes regarding any of the questions asked in this
form, I will immediately inform my contracts manager/supervisor/recruitment consultant and the Human
Resources department at HC Group.
Full name: ___________________________________________________________________________________
Date:
Signature:

For office use only

Form reviewed by: Date:

Comments:

Medical Self-Declaration Form Health Careers Group


Dated: October 2017 www.healthcareersgroup.in
Page 2 of 2

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy