Rangadore Memorial Hospital
1st Cross road, Shankarapuram,
Basavanagudi, Bengaluru - 560 004.
Employee Health Checkup Form
Personal History
Employee ID
*
Full Name
*
Gender
*
-- Select --
Male
Female
Prefer not to say
Other (please specify)
Date of Birth
*
Age
Age must be at least 15 years.
Emergency Contact Number
*
Duration of Service
*
Department
*
Select Photo
No image selected
Less than or equal to 2 Mb with white background
Health Information
Height
*
cm
Weight
*
kg
Blood Group
*
-- Select --
A+ve
A-ve
B+ve
B-ve
AB+ve
AB-ve
O+ve
O-ve
Not Known
Diet
*
-- Select --
Vegetarian
Non-vegetarian
Mixed
Other (please specify)
Smoking
*
Yes
No
Alcohol
*
Yes
No
Snuff
*
Yes
No
Allergy
*
Yes
No
Past Medical History
Diabetes
(High / Low blood sugar level)
*
Yes
No
Hypertension
(BP- blood pressure issues)
*
Yes
No
Heart disease
*
Yes
No
Kidney disease.
*
Yes
No
COPD / Asthma
*
Yes
No
Others
*
Yes
No
Instructions to be followed for health check up:
For blood tests, refrain from eating or drinking anything (except water) for 10 or more hours before the scheduled test.
Do not smoke during the fasting period.
Please abstain from consuming alcohol for 48 hours before the scheduled test.
Following these instructions will help ensure accurate and reliable test results.
Submit
