PRE EMPLOYMENT MEDICAL EXAMINATION FORM

Part I To be completed by the Candidate

PERSONAL DETAILS
SURNAME :	FORENAMES:
ADDRESS:	MARITAL STATUS :
DATE OF BIRTH:	PROPOSED Position:
NATIONALITY:	GENDER:
SOCIAL / OCCUPATIONAL HISTORY
1. Do you smoke? If so how many per day
2. If an ex-smoker, when did you give it up?
3. Average weekly alcohol consumption: state quantity and type
4. Have you been exposed to any known occupational hazard such as noise, radiation, dust, asbestos, chemicals or lead?
5. Have you used protective clothing, safety glasses or hearing protection?
6. Have you ever developed any medical condition in connection with your occupation? If so please give details e.g. Hearing loss/skin condition /wheeze/backache/muscle strain/blood disease?
7. Have you suffered any industrial injury? If so please give details.
8. Have you had any previous audiometric screening? Was this normal? State when and where?
9. Have you had previous lung function screening? Was this normal? State when and where?
10. Do you have any disabilities? Use a separate sheet if required
11. Have you ever been rejected from employment or insurance on medical grounds?
12. Have you received compensation for an industrial claim /or is there any industrial claim pending?
13. Have you ever been medivaced from an offshore installation? Give dates and details:
14. Have you been hospitalised in the last five years? If yes please provide details?':

Employee Name: Page 2

MEDICAL HISTORY REQUIRING SPECIAL CONSIDERATION
DO YOU HAVE OR HAVE BEEN DIAGNOSED AS SUFFERING FROM ANY OF THE FOLL0WING:
Please include any family history of the following in addition Please Elaborate
1. Chest pain / heart disease	YES	NO
2. High blood pressure / stroke	YES	NO
3. Asthma / epilepsy / diabetes	YES	NO
4. Peptic ulcer disease	YES	NO
5. Kidney disease (eg. Stones )	YES	NO
6. Psychiatric disorder eg. anxiety, Depression	YES	NO
7. Tuberculosis	YES	NO
8. Cancer	YES	NO
9. Have you or anyone in your family an existing medical condition?	YES	NO
10. Vaccination history: Poliomyelitis Tetanus Hep. A Hep. B BCG Meningitis Approx. Date:

DECLARATION

PLEASE READ THE FOLLOWING STATEMENT AND IF YOU AGREE, SIGN AND DATE.

“I DECLARE THE ABOVE TO BE TRUE TO THE BEST OF MY KNOWLEDGE. I AGREE THAT THE RESULTS OF THIS MEDICAL EXAMINATION, INCLUDING APPROPRIATE INVESTIGATION CARRIED OUT IN ORDER TO ESTABLISH MY MEDICAL FITNESS WILL BE REVEALED TO THE COMPANY MEDICAL OFFICER.

I ACCEPT THAT RASGAS WILL NOT BE LIABLE FOR ANY PRE-EXISTING MEDICAL CONDITION IN MYSELF OR MY DEPENDENTS UNLESS EXPRESSELY STATED IN WRITING”.”

SIGNATURE OF EXAMINEE:

DATE:

Part II – To be filled out by examining physician:

DO YOU HAVE OR HAVE YOU HAD ANY SIGNIFICANT OR RECURRENT PROBLEMS WITH THE FOLLOWING?

Please Elaborate

1. Backache / joint or muscular pain	YES	NO
2. Hernia / rupture	YES	NO
3. Visual impairment	YES	NO
4. Perforated eardrum / discharge from ear	YES	NO
5. Recurrent indigestion	YES	NO
6. Jaundice / hepatitis / gall bladder disease	YES	NO
7. Changes in bowel habit / diarrhea	YES	NO
8. Blood in stool / piles, hemorrhoids	YES	NO
9. Shortness of breath /coughing up blood	YES	NO
10. Recurrent bronchitis / pneumonia	YES	NO
11. Blood in urine / kidney complications	YES	NO
12. Headaches / migraine / dizziness	YES	NO
13. Varicose veins	YES	NO
14. Skin trouble (e.g. dermatitis / eczema)	YES	NO
15. Surgical operations	YES	NO
16. Hospitalization	YES	NO
17. Fear of flying / fear of heights	YES	NO
18. Tropical disease / venereal disease	YES	NO
19. History of alcohol / drug abuse	YES	NO
20. Do you have any allergies? Please list.	YES	NO
21. Do you have any current illnesses? Please list.	YES	NO
22. Are you receiving any medication at present? Please list.	YES	NO
23. Have you attended a dentist in the last year?	YES	NO
24. Are you undergoing dental treatment?	YES	NO
25. Date of last tetanus booster.	YES	NO
FOR FEMALES ONLY – HAVE YOU EVER HAD?
26. Abnormal smear / breast disease.	YES	NO
27. Gynecological problems e.g. pelvic infection.	YES	NO
28. Complications of pregnancy.	YES	NO
29. Please give date of last menstrual period.	YES	NO

EXAMINING PHYSICIAN’S COMMENTS

TO BE COMPLETED BY EXAMINING DOCTOR

HEIGHT

WEIGHT

BMI

PULSE

PEAKFLOW

PREDICATED

PFR

URINALYSIS

PROTEIN

BLOOD

GLUCOSE

VISION - DISTANCE

VISION - NEAR

COLOUR VISION

ISHIHARA TEST

AIDED L

NORMAL

AIDED R

ABNORMAL

BOTH

ELABORATE ON ABNORMAL FINDINGS

1. EYES/PUPILS

2. EAR, NOSE & THROAT

3. TEETH & MOUTH

4. LUNGS / CHEST

5. CARDIOVASCULAR

6. ABDOMEN

7. HERNIAL ORIFICES

8. RECTAL

9. GENITOUTINARY & TESTES

10. MUSCULOSKELTAL

11. SKIN

12. VARICOSE VEINS

13. NEUROLOGICAL

14. BREASTS

15. IDENTIFYING MARKS

(E.G. TATTOOS/SCARS ETC.)

INVESTIGATIONS

BLOOD HB / THICK FILM FOR MALARIA, MICROFILARIA

VDRL/RPR

HIV

HBs Ag.

ANTI. HCV

U&E, LFT’s

CHEST X-RAY

AUDIOMETRIC SCREENING

ECG

STOOL CULTURE

(CATERING STAFF)

OTHER

I CERTIFY THAT IS FIT / NOT FIT FOR SERVICE.

DATE OF MEDICAL

SIGNED:__________________________EXAMINING PHYSICIAN

CLEARED FIT FOR EMPLOYMENT ON MEDICAL GROUNDS.

NOT FIT FOR EMPLOYMENT ON MEDICAL GROUNDS

__________________________