8/10/2019 4.-Pre-Employment-Medical-Form.pdf

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Position offered: Grade: Date:

Age: Date of Birth: No. of Children, if any:

Sex: Marital Status: Tel.No: Email:

Home Address:

Medical History : ( If " Yes", please provide detailed report )

Do you have or been treated for: Yes No Yes No

1. Epilepsy, fits or migraines 8. Any history of Diabetes

2. Psychiatric or psychological disorders 9. Menstrual disorders / Dysmenorrhoea

3. Ear, nose & throat disorders.

4. Back pain & Joint Disorders 11. Visual problems & Colour Blindness

5. Any kind of heart disease / Hypertension

6. Allergies & Skin disorders 13. Current medications (prescriptions and OTC)

7. Previous Medical or Surgical treatment (or 14. Any other medical illnesses (Cancer, blood

any serious injury) disorder, etc..)

Blood Group Type: (Please tick the correct box)A+ A - B+ B - AB+ AB - O+ O -

Note: Please bring a blood group certificate as it is required by State of Qatar (to acquire Work permit)

Medical Examinations required by State of Qatar: (To acquire Work Permit/Residence Visa)

1.) Chest X-Ray (* High Resolution)

2.) HIV 1 & 2

3.) HCV

4.) HBsAg

( * ) Chest X-Ray should not have any lesion including past tuberculosis lesion, scar or calcified node / granuloma.

Additional Medical Examinations Required by Qatar Airways :

GENERAL STAFF

1.) ECG: (>50 yrs.)

TECHNICAL STAFF

1.) Visual Acuity / Colour Vision2.) Hearing ( Audiogram )

FOOD & BEVERAGE STAFF

1.) Hep A (Igm)2.) Stool Exam

NOTE:

1. Any medical condit io n not d eclared in th e Medical History Questionn aire and detected later may

result in termination of your employment.

2. If, for any reason, you do n ot pass the Qatar Government m edical exam, this offer o f employm ent wil l be

withdr awn and you wil l be repatriated to your hom e country. The comp any is not responsible for any lossessustained or inco nvenience caused as a consequence of fai l ing the Qatar Medical Commission Examination.

advance prior to joining th e company. Please note that medical expenses incurred wil l n ot be reimbursed.

Declaration & consent to obtain medical information:

I hereby declare that I have carefully considered the statement(s) made above and that I have not witheld any relevant information or made any misleading

statement. I understand that if I have made any false representation for the purpose of procuring for myself a medical certificate, I may be guilty of a criminal

offence. I hereby consent to the Qatar Airways Medical Centre obtaining information about my health from any medical advisor or hospital consulted by me.

_________________ _________________________

Date

Pre Employment Medical Questionnaire

Full Name: Nationality:

3. If you are unsure if yo u w il l pass the above m edical tests, please arrange for these tests to be taken in

10. Tuberculosis or asthma

12. Does the applicant smoke?

Candidate's signature

QRMC Medical Form 001/06 Page 1/1