Medical Report Form

July 12, 2011

There are instances when you will be required to provide a medical report form.  Some companies request a medical report form in cases where your fitness is a requirement for effective execution of duties.  It is important to note that this report cannot and should not be used to discriminate against individuals.

Sample Medical Report Form

Please fill out the following details concerning the applicant.

Applicant’s name: _____________________ Middle name: __________________

Last name: _____________________ Gender: __________________

Mr. / Ms/ Mrs.: ____________________ Date of birth: __________________

Address: ______________________ State: __________________

Location: ________________________ Zip code: _____________________

Tel no: ___________________ Mob no: ______________________

Fax no: ________________________ Email address: _________________

This section of the form should only be filled out by a qualified Physician.

Please state the general health status of the applicant.

__________________________________________________________

Please state any health related issues of the applicant that hinder him from executing his/ her duties.

_____________________________________________________________

Physician’s name: ____________________ Address: ______________________

Sig: ______________________ Date: __________________

 

Download Medical Report Form in Word Format

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