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    Malaysia Pre Employment Medical Examination Form

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    nageshnagpur
    The document is a pre-employment medical examination form for an individual applying for a country manager position. It collects personal details and medical history information through a series of yes or no questions. The questions cover topics like health conditions, vaccinations, hospitalizations, disabilities, and prior rejections from employment or insurance. The individual signs declaring the information provided is true.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Malaysia Pre Employment Medical Examination Form

    Uploaded by

    nageshnagpur
    310 views4 pages
    The document is a pre-employment medical examination form for an individual applying for a country manager position. It collects personal details and medical history information through a series of yes or no questions. The questions cover topics like health conditions, vaccinations, hospitalizations, disabilities, and prior rejections from employment or insurance. The individual signs declaring the information provided is true.

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    Malaysia pre employment medical examination form

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    The document is a pre-employment medical examination form for an individual applying for a country manager position. It collects personal details and medical history information through a series of yes or no questions. The questions cover topics like health conditions, vaccinations, hospitalizations, disabilities, and prior rejections from employment or insurance. The individual signs declaring the information provided is true.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    310 views4 pages

    Malaysia Pre Employment Medical Examination Form

    Uploaded by

    nageshnagpur
    The document is a pre-employment medical examination form for an individual applying for a country manager position. It collects personal details and medical history information through a series of yes or no questions. The questions cover topics like health conditions, vaccinations, hospitalizations, disabilities, and prior rejections from employment or insurance. The individual signs declaring the information provided is true.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    MALAYSIA PRE EMPLOYMENT MEDICAL EXAMINATION FORM

    Part I To be completed by the Candidate


    PERSONAL DETAILS
    SURNAME: DWIVEDI FORENAMES: NAGESH
    PASSPORT NO: Z7664065
    ADDRESS: MARITAL STATUS:

    DATE OF BIRTH: 05/05/1979 PROPOSED POSITION: COUNTRY


    MANAGER
    NATIONALITY: INDIAN GENDER: MALE
    SOCIAL / OCCUPATIONAL HISTORY: EMPLOYEE
    1. Do you smoke? If so how many per day no

    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 mediated from an


    offshore installation?
    Give dates and details:

    . 14. Have you been hospitalized in the last five years? If yes
    please provide details?':
    Employee Name: NAGESH DWIVEDI
    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 YES
    family an existing medical condition? 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.

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

    SIGNATURE OF CANDIDATE:
    DATE:

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