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Annexure - Self Declaration of Medical History - English

The document is a self-declaration form for Aarti Industries Limited, where candidates provide their medical history and health conditions. It includes a checklist of various health issues, past surgeries, and lifestyle habits that candidates must disclose. The form concludes with a declaration of truthfulness and a signature section for the candidate.

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suwarenikhil011
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29 views2 pages

Annexure - Self Declaration of Medical History - English

The document is a self-declaration form for Aarti Industries Limited, where candidates provide their medical history and health conditions. It includes a checklist of various health issues, past surgeries, and lifestyle habits that candidates must disclose. The form concludes with a declaration of truthfulness and a signature section for the candidate.

Uploaded by

suwarenikhil011
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: Age/Sex:
Agency Name: Function:
Emp. code/
Division Name:
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
2 Diabetes Mellitus (Blood Sugar Problem)
Heart related problems - Chest pain, Heart Attack, Congenital conditions, valvular
3
heart disease etc.
4 Respiratory related problems - Asthma/Shortness of breath/Chronic cough etc.
5 Nervous system related problems - Convulsion/Fits/Paralysis/Polio etc.
6 Liver/Gall Bladder related problems like jaundice /Hepatitis/Gall stones etc.
Digestive system related problems - Peptic ulcer/bloody vomiting or
7
stool/irregular bowel habits etc.
8 Kidney related problems - Renal stones/Blood in urine etc
Blood related problems - Anemia/Low platelet count/Sickle cell
9
anemia/Thalessemia etc.
10 Any endocrine related disorder like thyroid conditions etc
Musculoskeletal disorders - Backache/Limb deformity/disc problem/joints
11
problem etc.
12 Eye related problems - Refractive errors/colour blindness/squint/cataract etc.
13 Do you wear any contact lenses?
14 Ear related problems - Ear discharge/hearing loss/tinnitus etc.
15 Skin related problems - Rashes/psoriasis/scars etc.
Are you suffering from any communicable diseases? - Tuberculosis/HIV/Hepatitis
16
B /Leprosy etc.
17 Mental Health related problem
18 Any Allergy - Drug/Food/Other
19 Vertigo / Giddiness
20 Phobia (Fear of hight or closed places/darkness)
21 Ankle swelling/Hernia / Hydrocele/Abdominal swelling etc
22 Any history of hospitalisation in past?
23 Any history of past surgeries?
24 Consumption/Habit - Drug/Alcohol/Tobbaco/Smoking?
25 Any history of long term medications? OR currently taking any medication?
26 Any history of occupational injuries/illness in past?
27 Any past history of cyanosis? (Bluish discolouration of tongue/lips/nails)
Family History of Diabetes/Hypertension/Heart Attack/Mental disorder/
28
Asthma/cancer
Last Menstrual Period ____________
29 For Female
Any gynaecological disorder?
30 Any present complaints?

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:
Place: ______________________________

Sign/Left thumb Impression of candidate

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