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8 views

Self declaration

Uploaded by

10prasaad
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Aarti Industries Limited

Self Declaration of Medical History


Name: PRASAD DHANAJI HUNDLEKAR Age/Sex: 25/M
Agency Name: Function:
Division Name: Emp. code/ Gate pass No:

Do you have any of the following health problems? Yes No Remark


If Yes, specify in remark coloum
1 High / low blood pressure P
2 Diabetes Mellitus (Blood Sugar Problem) P
3 Heart related problems - Chest pain, Heart Attack, Congenital conditions, valvular heart disease etc. P
4 Respiratory related problems - Asthma/Shortness of breath/Chronic cough etc. P
5 Nervous system related problems - Convulsion/Fits/Paralysis/Polio etc. P
6 Liver/Gall Bladder related problems like jaundice /Hepatitis/Gall stones etc. P
7 Digestive system related problems - Peptic ulcer/bloody vomiting or stool/irregular bowel habits etc. P
8 Kidney related problems - Renal stones/Blood in urine etc P
9 Blood related problems - Anemia/Low platelet count/Sickle cell anemia/Thalessemia etc. P
10 Any endocrine related disorder like thyroid conditions etc P
11 Musculoskeletal disorders - Backache/Limb deformity/disc problem/joints problem etc. P
12 Eye related problems - Refractive errors/colour blindness/squint/cataract etc. P
13 Do you wear any contact lenses? P
14 Ear related problems - Ear discharge/hearing loss/tinnitus etc. P
15 Skin related problems - Rashes/psoriasis/scars etc. P
16 Are you suffering from any communicable diseases? - Tuberculosis/HIV/Hepatitis B /Leprosy etc. P
17 Mental Health related problem P
18 Any Allergy - Drug/Food/Other P
19 Vertigo / Giddiness P
20 Phobia (Fear of hight or closed places/darkness) P
21 Ankle swelling/Hernia / Hydrocele/Abdominal swelling etc P
22 Any history of hospitalisation in past? P
23 Any history of past surgeries? P
24 Consumption/Habit - Drug/Alcohol/Tobbaco/Smoking? P
25 Any history of long term medications? OR currently taking any medication? P
26 Any history of occupational injuries/illness in past? P
27 Any past history of cyanosis? (Bluish discolouration of tongue/lips/nails) P
28 Family History of Diabetes/Hypertension/Heart Attack/Mental disorder/ Asthma/cancer P
Last Menstrual Period ____________ NA
29 For Female Any gynaecological disorder? NA
30 Any present complaints? NA

Additional Remark

I hereby declare that, to the best of my knowledge and belief, the particulars given above and the declaration made therein are true.
For non-routine work only : I hereby declare that I will not work in chemical process areas in violation of the company policy.

Date: 24-07-2023
Place: ROHA PRASAD DHANAJI HUNDLEKAR

Sign/Left thumb Impression of candidate

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