NAME : PASSPORT NO : POSITION APPLIED FOR :

PAST MEDICAL HISTORY

A) Venereal Disease : ................................................................................................................................................................. B) Any Significant Illness : ...........................................................................................................................................................

LEFT EAR: ........................................................................................................................................................... RIGHT EAR: ........................................................................................................................................................... LEFT EYE: ........................................................................................................................................................... RIGHT EYE: ........................................................................................................................................................... SURGERY: ........................................................................................................................................................... CXR: ........................................................................................................................................................... LIVER: a) LFT: ........................................................................................................................................................... b) Vaccines: ........................................................................................................................................................... BILHARZIA: ........................................................................................................................................................... TB: ........................................................................................................................................................... MALARIA: ........................................................................................................................................................... DM (URINE ANALYSIS): ........................................................................................................................................................... BP: ........................................................................................................................................................... SEROLOGY VDRL / TPHA : ........................................................................................................................................................... HIV ANTIBODY:........................................................................................................................................................... PREGNANCY (if applicable): ........................................................................................................................................................... ANTI HBe: ........................................................................................................................................................... ANTI HBs: ........................................................................................................................................................... ANTI HBc: ........................................................................................................................................................... BP: TOTAL: ........................................................................................................................................................... IgG : ........................................................................................................................................................... IgM : ........................................................................................................................................................... HBcAg: ........................................................................................................................................................... HCAb: ........................................................................................................................................................... OTHER DISEASE : ...........................................................................................................................................................

The above person is : Fit for employment NOT fit for employment

Physician: ............................................................ Address: ............................................................ Date :............................................................ Signature:............................................................