Pre Employment Medical Questionnaire

Position offered:
Full Name:
Age:
Sex:
Home Address:

Grade:
Nationality:
No. of Children, if any:
Tel.No:

Date of Birth:
Marital Status:

Date:

Email:

Medical History : ( If " Yes", please provide detailed report )

Do you have or been treated for:

Yes No

Yes No

1. Epilepsy, fits or migraines

8. Any history of Diabetes

2. Psychiatric or psychological disorders

9. Menstrual disorders / Dysmenorrhoea

3. Ear, nose & throat disorders.

10. Tuberculosis or asthma

4. Back pain & Joint Disorders

11. Visual problems & Colour Blindness

5. Any kind of heart disease / Hypertension

12. Does the applicant smoke?

6. Allergies & Skin disorders

13. Current medications (prescriptions and OTC)
7. Previous Medical or Surgical treatment (or
14. Any other medical illnesses (Cancer, blood
any serious injury)
disorder, etc..)
Blood Group Type: (Please tick the correct box)
A+
AB+
BAB+
AB O+
ONote: Please bring a blood group certificate as it is required by State of Qatar (to acquire Work permit)
Medical Examinations required by State of Qatar: (To acquire Work Permit/Residence Visa)
1.) Chest X-Ray (* High Resolution)
2.) HIV 1 & 2
3.) HCV
4.) HBsAg
( * ) Chest X-Ray should not have any lesion including past tuberculosis lesion, scar or calcified node / granuloma.
Additional Medical Examinations Required by Qatar Airways :
GENERAL STAFF
1.) ECG: (>50 yrs.)
TECHNICAL STAFF
1.) Visual Acuity / Colour Vision
2.) Hearing ( Audiogram )
FOOD & BEVERAGE STAFF
1.) Hep A (Igm)
2.) Stool Exam
NOTE:
1. Any medical condition not declared in the Medical History Questionnaire and detected later may
result in termination of your employment.
2. If, for any reason, you do not pass the Qatar Government medical exam, this offer of employment will be
withdrawn and you will be repatriated to your home country. The company is not responsible for any losses
sustained or inconvenience caused as a consequence of failing the Qatar Medical Commission Examination.
3. If you are unsure if you will pass the above medical tests, please arrange for these tests to be taken in
advance prior to joining the company. Please note that medical expenses incurred will not be reimbursed.
Declaration & consent to obtain medical information:
I hereby declare that I have carefully considered the statement(s) made above and that I have not witheld any relevant information or made any misleading
statement. I understand that if I have made any false representation for the purpose of procuring for myself a medical certificate, I may be guilty of a criminal
offence. I hereby consent to the Qatar Airways Medical Centre obtaining information about my health from any medical advisor or hospital consulted by me.

_________________
Date
Date:

QRMC Medical Form 001/06

_________________________
Candidate's signature

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