Medical Report Form
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: _________________________
Category: Report Forms
