MEDICAL CERTIFICATE OF FITNESS

Important Instructions:
1. The Candidate must ensure that a legally qualified and registered medical practitioner with minimum qualification as
M.B.B.S. completes this form. Additional sheets may be attached if more space is required.
2. The candidate is responsible for any costs associated with the preparation of this report.
3. Please hand over the complete form to your local HR at the time of joining.

SECTION - 1 (to be filled by the Candidate)

Candidates Personal Details
first name

Name
Gender

middle name

Male

Date of birth

last name

Female
DD

MM /

Blood Group:

YYYY

Contact No. (Mobile)

paste a passport
size color
photograph
attested by your
consulting doctor

(Resi.)

Candidate's Statement
Do you have any congenital defect/abnormality?
Yes

No. (If yes, provide details)

Do you have any physical deformity/handicap or use any mechanical/physical assistance for mobility?
Yes

No. (If yes, provide details)

Have you had any form of serious illness or operation in the last two years?
Yes

No. (If yes, provide date and details of surgery)

Have you been treated/hospitalized for cancer/Tumor/Cyst or any other growth?

Yes

No. (If yes, provide details)

Has medical grounds been a reason for un-employment or you not performing a specific role in the past?
Yes

No. (If yes, provide details)

Have you ever suffered or suffering from any of the following?

High/Low Blood Pressure

Stroke

Bronchitis

Diabetes/Hypoglycemia

Arthritis

Peptic Ulcer

Heart Disease

VD Tests Positive

Tuberculosis

Epilepsy

Glaucoma

Color Blindness

Thyroid Ailment

Heart attack

Slipped disc

Liver disease

Asthma

Have you ever suffered or suffering from any other illness or impairment not mentioned above?
Yes

No. (If yes, provide details)

Are you presently in a medical condition (including pregnancy) that may require you to be away from work in the next 12
months?
Yes
No. (If yes, provide details)

Candidate's Declaration
I declare that to the best of my knowledge, the answers to the questions in this form are correct and that I am not suffering from
any disease/illness, the presence of which I have not revealed. I fully understand that any misrepresentation of this declaration
could lead to the termination of my offer/appointment. I have no objection to CMC Ltd. seeking further information either
directly from me or from my Consulting doctor or other appropriate doctor. In case of any discrepancy arising out of my
declaration, I will be undergoing the medical check-up by the Companys suggested medical clinic/doctor and their findings will
be fully binding on me and any action thereon towards my employment will be accepted by me.

Signature

Date

Section - 2 (to be filled by the Medical Practitioner)

Medical Practitioners Details
Full name (as listed on the applicable State registry)
Registration ID:
Postal Address:

Contact Number (Day time)

General Examination
Body wt:

Kgs

Height:

cms.

Pulse:

/min.

BP:

mm Hg

Declaration
I certify that I have carefully examined Mr/Ms
Son/Daughter of
S/HE IS MEDICALLY

FIT

UNFIT

for employment with CMC Ltd.

Remarks:

Signature

Seal

Date