HEALTH DECLARATION — Applicant for Employment “APPENDIX-D” Please complete and return this Health Declaration as soon as possible. If you need more space please attach a ‘separate sheet of paper. The information you provide wil be considered as part of our normal enquires in connection with your application for employment. If you knowingly give felse information or wilfully suppress any material fact, you willbe liable to summary dismissal. ‘Sumame (Block Letters) S¥Y!P\41... NRIC ...230608-06-SS22 Other Names (in full) SUHAL'..GINTL moti. uss int Ne 2S Address..NO:.. 2M. ABLAC patingra. 2S. Dato ofBith 28, Out ISS. tedead,..awT ss wens Telphone Wo, 211. ASHSEIE, Reareeoy Caan S » Postoode .. 2222.0... 2 Job for which you have applied. .G.LOSML.. SNPPORT... EXECUTIVE 3 Height (without shoes) (SL (cm) _—_ Weight (in indoor clothes without shoes) (kg) Yes or No | (ifappropriate give further detai & (@) Have you ever lef any employment on grounds of il health or irregular attendance? ne {(B)_Have you been refused any employment on medical grounds? [Ne (©) Has ary insurance company decined to accept a proposal fo insure your lfe, or imposed special conditions? No 5 (@) Have you ever had:-fits, fainting attacks, blackouts or ay epilepsy? ° (B)_ mental i-health, nervous breakdown, other nervous problems, 7 anxiety, depression, phobias or stress-related problems? _ we (© heart trouble, including rheumatic fever cr high blood pressure? “No (hay fever, asthma, allergies, bronchitis, tuberculosis or other |, 5 chest disease? iM (@)_gastric or duodenal ulcer or other digestive or bowel disorger? [wo | (f)_kidney disease or bladder trouble (inchiding stone orgravel)? | > (q)_arthntis, rheumatism or gout? wo (h)_any back or joint trouble, including sipped (prolapsed) disc? NO (i)__any neck, shoulder or upper limb probierns? NO (any blood disease? No k)_any skin disease? No (diabetes? NO (mn)_eye problems/disease? NO (n)_ear problesidisease? No (0) _hemiairupture? No (p)_vancose veins? No (q)_ treatment by radio therapy or chemotherapy’ NOYesiNo | (if appropriate give further details) © (a) | your eyesight satisfactory for all normal purposes inciuding | yc the use of display screen equipment? . (b) Do you wear glasses/contact lenses? ves {e) fs your hearing in each ear good for all purposes inclucing use |, ofthe telephone? os (@) Do you have any speech difficuities? No (©) Do you have any difficulty with physical mobility? Ne (f) Do you have a requirement for eny special faciities or| equipment? ® 7 _Doyousmoke? ¥ES(NO” If “Yes’, how many do you smoke daily? 8 _Are you aware of having any other liness/disabilty not covered by this questionnaire? ESO) Ifyes please provide details 9 Have you ever had treatment in hospital or have you been attended to by a doctor (excluding influenza, Gammon cold, common childhood diseases and minor ailments)? YES/NO Ite answer is YES please give the following particulers for each occasion: Nature of aiment Dates of beginning and end of | Approximate total (use a separate line for each) lines (as near as you can give | curation of absence due them) ‘o this aliment (weeks/days) 10 Please give an account of any absences from work due to minor ailments during the last two years:- Nature of ailment ‘Approximate number of ‘Approximate total (use a separate line for each) absences due to this ailment | duration of absence due to this ailment (weeks/days)14 Are you presently under medical supervision or ilin any way? YESNO Please provide detals 12 State any medication currently prescribed for your USE «n.d LA. 13 | declare that all the statements made on this form are true and complete to the best of my knowledge and elit J understand that | may be required to undergo a medical examination prior to my employment and at any time during the course of my employment by my employer. Note: Any false, misieading or incomplete information may result in the offer being withdrawn or in summary dismissal Signature of Applicant... ate IP nena Ifyou have any queries regarding the Contents of this form you can get in touch with the Human Resources Department.