MEDICAL EXAMINATION FORM
DATE:
QP - CONTRACTORS PERSONNEL MRN NO:
SECTION A: HEALTH SCREENING QUESTIONNAIRE
1. PERSONAL DETAILS: To be completed by the examinee or his company representative
Full name: Gender: M F
Date of Birth: Marital Status:
Nationality: Religion: ID No.:
Job Title:
Company Name:
QP Sponsor Dept:
Home Address:
Mobile: Email:
Supervisor Name: Mobile:
Local Doctor Name:
Phone No.:
Date of Last Medical Check-Up
2. SOCIAL/OCCUPATIONAL HISTORY: To be completed by the examinee and Nurse/Doctor
Do you smoke? Yes No (X as appropriate & elaborate) If an ex-smoker, when did you give up?
If yes how many per day?
Do you drink alcohol? Yes No. If yes mention weekly consumption.
Have you ever been exposed to below mentioned occupational hazard? (X as appropriate)
Noise Radiation Dusts Asbestos Chemicals Lead
Have you ever developed any medical condition due to your occupation? Yes No
If yes (X as appropriate)
Hearing Loss Skin condition Wheeze Backache Muscle strain Blood diseases
Have you ever suffered any industrial injury? If yes give details below:
Have you had any previous audiometric screening? Yes No
If yes was this normal? Yes No
Have you had previous lung function test? Yes No
If yes was this normal? Yes No
Have you ever been rejected from employment on medical grounds? Yes No
3. MEDICAL HISTORY: To be completed by the examinee and Nurse/Doctor.
Do you have or have you been diagnosed
N Y (Put a X as appropriate & elaborate if Yes)
as suffering from any of the following?
Chest pain/Heart disease
High Blood pressure
Diabetes
High Cholesterol
Asthma
Epilepsy
Peptic ulcer disease
Any Kidney problem
Any Psychiatric problem
Tuberculosis
Any Cancer
Backache / joint or muscular pain
Hernia
Visual impairment
Perforated ear/ discharge
CONFIDENTIAL ONCE COMPLETED Page 1 of 3
MEDICAL EXAMINATION FORM DATE:
QP - CONTRACTORS PERSONNEL MRN NO:
Recurrent indigestion
Jaundice/hepatitis/Gall stones
Change in bowel habit / diarrhoea
Blood in stool / piles, hemorrhoids
Shortness of breath
Recurrent bronchitis / pneumonia
Coughing up blood
Headaches / migraine / dizziness
Varicose veins
Skin problem
Any surgical operations
Any hospitalization in past 10 yrs
Fear of flying / fear of heights
Any tropical diseases
Any STDs
Do you have any allergies?
Any current illnesses?
Are you on any medication?
Undergoing dental treatment?
Any other medical condition not listed above? Please provide details:
4. VACCINATION RECORDS: To be completed by the examinee and Nurse/Doctor
(Please circle Y-yes, N-no and mention the date of booster dose)
Tetanus Y N Hep A Y N
Diphtheria Y N Hep B Y N
Polio Y N Yellow Fever Y N
Typhoid Y N BCG Y N
Others(List here)
5. CONSENT & DECLARATION: To be completed by the
examinee
“I declare the above to be true to the best of my knowledge. I agree that the result of my medical
examination, including appropriate investigations carried out in order to establish my medical fitness
may be revealed to a QP/Company/GMC Medical Officer if required. I accept the transfer of my
medical files to other doctors working for QP/ Company in which I am employed/may gain
employment”.
Non declaration of significant medical problems may result in termination of
employment.
Attach a
recent passport
size photograph
of the examinee
Date: Signature of Examinee
CONFIDENTIAL ONCE COMPLETED Page 2 of 3
SECTION B: MEDICAL EXAMINATION
1. NURSING ASSESSMENT: To be completed by nursing staff
Height(cms) Weight(kgs) BMI Pulse (min) BP Colour Vision PEFR(L/min)
Normal
Abnormal safe
Abnormal unsafe
Distant Vision Spoken voice Spirometry Urinalysis /Dipstick
Uncorrected Corrected Normal FEV1 - Protein Blood Glucose
R R Abnormal
FVC -
Normal
L L Abnormal FEV1/FVC
2. PHYSICIAN ASSESSMENT: To be completed by the examining Doctor
System Normal (N) Comment on any significant medical or surgical history mentioned in the health
Abnormal (AB) questionnaire or ongoing treatment, medications and abnormal clinical findings.
General
Eyes
ENT
Teeth
Lungs/Chest
Cardiovascular
Abdomen
Hernial Orifices
Genitourinary
Musculoskeletal
Skin
Varicose vein
Neurological
Endocrinological
Investigations: Normal (N) Attach original report/tracings. Not required (NR). Abnormal (AB) & comment.
Blood test
CXR
ECG
Spirometry
Audiometry
VO2 max
3. REQUIRED HEALTH MONITORING AND MEDICAL SURVEILLANCE (√ as appropriate) Obesity
Hypertension Respiratory disorder Liver Disorder Lipid Disorder
Neoplasm Kidney disorder Mental problem
Diabetes CVS disorder Infectious diseases Hearing conservation
Others:
4. INITIAL FITNESS TO WORK STATUS: To be completed by examining Doctor (√ as appropriate
Fit Fit with follow-up Fit with surveillance Temporary Unfit Fit with restrictions
Need specialist opinion Unfit Other(Specify)
Physician Name: Date:
Signature Stamp
