Pre-Employment Health Declaration Form
Full Name
Date of Birth
Position Applied For
Contact Number
Email Address
Do you have any of the following medical conditions? (Tick all that apply)
Diabetes
Hypertension
Asthma
Heart Disease
Others
Are you currently taking any medications?
Yes
No
If yes, please specify
Have you had any major surgeries or hospitalizations in the past 5 years?
Yes
No
If yes, please provide details
Do you have any allergies?
Yes
No
If yes, please specify
Additional Information
I declare that the information provided above is true and complete to the best of my knowledge.
Signature
Date