Pre Employment Medical Questionnaire

June 8, 2011

Title:

Name:

Middle Name (if any):

Surname:

Date of Birth:

Sex:

Present Address:

Telephone No.:

Position applied for:

Please answer the following questions in ‘Yes’ or ‘No’. If the answer is ‘Yes’, then please give details.

1)   Have you ever suffered from any visual defects or illness (including genetic conditions like colour blindness)?

2)   Have you suffered from any hearing disorders or defects?

3)   Do you suffer from depression or severe anxiety or any other psychiatric disorders?

4)   Do you suffer from headaches, vertigo, migraine etc.?

5)   Do you suffer from asthma, emphysema or any other respiratory disorders?

6)   Have you suffered from any diseases of the kidney, heart, liver or pancreas?

7)   Do you suffer from immunological diseases?

8)   Do you take any medication for any such diseases or defects?

9)   Have you ever undergone a surgery?

10)               Have you ever been admitted to a hospital for your deteriorating condition?

11)               Have you suffered from an industrial disease or accident?

12)               Are you consulting a doctor or physician at present?

13)               Are you undergoing any prescribed medication presently?

14)               Are you a smoker?

15)               If yes, how many cigarettes do you have each day?

16)               Do you drink alcohol regularly?

17)               Do you have any physical condition that requires you to use any aid?

18)               Do you have any other health problems, related to this?

Download Sample Pre Employment Medical Questionnaire in Word Format

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