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Medical Declaration Form Template

This document is a medical declaration form for a job applicant. It collects information about the applicant's family medical history, current health status and treatment, past illnesses, and risky health behaviors. The applicant must disclose any hereditary disorders or diseases that affected family members prior to age 60. They are also asked whether they currently take any medications or have seen a doctor in the past 5 years. Finally, the applicant must certify that all medical information provided is true and consents to the collection and processing of their personal data.

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Jae Wai
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98 views3 pages

Medical Declaration Form Template

This document is a medical declaration form for a job applicant. It collects information about the applicant's family medical history, current health status and treatment, past illnesses, and risky health behaviors. The applicant must disclose any hereditary disorders or diseases that affected family members prior to age 60. They are also asked whether they currently take any medications or have seen a doctor in the past 5 years. Finally, the applicant must certify that all medical information provided is true and consents to the collection and processing of their personal data.

Uploaded by

Jae Wai
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Medical Declaration Form

Family Name: __________________________ Given Name: _________________________

Date of Birth: ____/____/____ Sex: MALE FEMALE


(mm/dd/yy)

Position applying for: _________________________

FAMILY HISTORY OF THE APPLICANT

NAME FAMILY MEMBERS DECEASED FAMILY MEMBERS


(Last Name, First Name, Middle name) AGE STATE OF HEALTH AGE OF DEATH CAUSE OF DEATH

FATHER

MOTHER

BROTHERS
& SISTERS

MEDICAL EXAMINATION FOR APPLICANT

 Please circle your answer to each questions

1. Have any of your parents, brothers or sisters had any hereditary disorders, high YES / NO
blood pressure of diabetes prior to age 60?

2. Are you under medical treatment by diet, medicine or other means? YES / NO

3. Within past five (5) years, have you:


YES / NO
a.) consulted any doctor or other health practitioner?

b.) submitted to ECG, X-rays, blood test or other test? YES / NO

c.) attended or been attended to in any hospital or other medical facility? YES / NO

d.) had any sexually transmitted disease? YES / NO


4.) Have you ever had tumor, limp, mass, cyst (cancerous of benign), or abnormal YES / NO
bodily Growth?

5.) Have you ever consullted or been treated by physician for:


a.) chest pain*, high blood pressure*, heart disorder or murmur? YES / NO

b.) asthama*, chronic cough*, shortness of breath or lung disorder? YES / NO

c.) diabetes*, or sugar in urine? YES / NO

d.) ulcer*, colitis*, chronic diarrhea, hepatitis or other liver* or digestive YES / NO
disorder?

e.) cancer, tumor, enlarged glands or enlarged lymph nodes? YES / NO

f.) anemia, bleeding or blood disorder? YES / NO

g.) fainting spells, epilepsy*, nervous or mental disorder? YES / NO

h.) urine, kidney*, or bladdder disorder? YES / NO

i.) arthritis? YES / NO

j.) any other illnes, surgery or injury? YES / NO

k.) Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related YES / NO


Complex (ARC)?

l.) a test indicating the presence of the Human Immuno-Deficiency Virus YES / NO
(HIV)?

6.) Do you now have or have you ever had any other illness, disease, injury,
YES / NO
deformity or physical defect?

7.) Do you smoke or have you ever smoked tobacco or any of its products? If yes,
how many sticks per day, or how long have you been smoking and reason for
YES / NO
stopping(if applicable)?

8.) Do you consume alcoholic beverages? If yes, how much per sitting? YES / NO

9.) Except as prescribed by a physician, have you ever use cocaine, heroin or other
narcotics, marijuana, LSD or amphetamines?
YES / NO

10.) Have you ever used/taken habit forming drugs or sought advice for alcoholism, YES / NO
drug abuse or other form of substance abuse?

11.) Do you have any health symptoms or complains for which a physician has not
YES / NO
been consulted or treatment has not been received?

ANSWERED BY WOMEN ONLY

1.) Have you ever had gynecological problem(e.g. menstrual disorder or symptom of YES / NO
disease of breast, uterus or ovaries)?

YES / NO
2.) Have you had any complication or abnormal pregnancy(e.g. miscarriage or
premature labor, ectopic caesarian)? If yes, please describe

I hereby certify that the information I have provided in terms of my


medical history is true, complete, and correct, and that all other
documents submitted in relation thereto are genuine, accurate and
authenticate.

I I hereby agree to the PRC Privacy Notice and give my consent to


the collection and processing of my personal data in accordance
thereto.

________________________________
Signature of applicant over printed name

____________________________________
Date accomplished

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