HEALTH CHECK & CONSENT FORM

MEDICAL - CONFIDENTIAL
SECTION A: PERSONAL INFORMATION
Name:
Address:

Date Of Birth:
Male / Female
Home Phone:
Email :
Job Title:

Site:

Mobile :

CONSENT TO HEALTH SCREEN, HEALTH MONITORING, RECORD RETENTION AND RELEASE OF MEDICAL
INFORMATION
I understand that the Health Check I am about to undergo will provide information to International SOS Services
(India) Pvt. Ltd., to evaluate my state of health.
I hereby acknowledge and understand that:
(i) I agree to undergo medical health checks & vaccinations (the Health Checks and diagnostic tests, for
purposes of determining my fitness for work).
(ii) Intl.SOS will assist to make referrals for me to undergo Health Checks conducted by independent third-party
physicians (the Medical Service Providers). In making such referral:
a. Intl.SOS will not be responsible for the Health Checks nor be liable for any consequences arising out
of or caused by the services provided by the Medical Service Providers, including but not limited to,
the diagnostic processes, accuracy and interpretation of results provided by the Medical Service
Providers; and
b.

Intl.SOS nor the Medical Service Providers assume any responsibility to diagnose any medical
condition I may have or to treat me, or to undertake responsibility for my ongoing care

(iii) The Health Checks I will undergo will simply allow the Medical Service Providers and Intl.SOS to evaluate my
state of health and fitness for work based upon guidelines provided by my employer.
(iv) The information provided in the Health Checks will be processed and retained in the Intl.SOS Medical
Department. To this extent, I hereby further authorize International SOS to:
a. Maintain my Health Check results together with my medical history; and
b. Release my examination and health records; and
c.

Provide a summary of medical recommendations to a designated medical practitioner in my company

in a confidential manner

d. Provide access to a summary of health screening results in emergency situations.

(v)

I have the option of consulting or rectifying my medical file upon request to do so in writing to the
authorized Doctor of Intl.SOS'.

(vi)

Intl.SOS does not control the requirement to undergo the Health Checks and has a limited role in making
recommendation on fitness based on my companys health guidelines. I further acknowledge that any
employment-related decisions in connection with the Health Checks are the sole responsibility of my
employer.

By signing this consent form, I confirm that I have read and fully understood the above terms and conditions. I also
declare that statements made on this form are to the best of my knowledge accurate and all known medical history
has been stated.
Consent given on (date) ____________ By (Print Name) _______________________
Signature_____________________________
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SECTION B: MEDICAL HISTORY

Yes

No

Doctors Comments
( All Yes responses)

Are you being treated by a doctor for any illness?

Are you taking any regular medication?
Have you ever had any operations or accidents?
Have you ever had any broken bones
Do you suffer from or Have you ever suffered from:
Lung problems (including Tuberculosis)
Wheezing /bronchitis /Asthma
Diabetes
High Blood pressure
Heart Disease (including Heart Attack, Heart Surgery,
murmurs, palpitations, angina)
Shortness of breath or chest pain on exertion
Stomach pains or Ulcers
Hernia
Thyroid Disease
Fits/Blackouts/Dizziness
Epilepsy
Severe Head or spinal injury resulting in hospitalization
Allergies or Hay fever
Skin disorders /dermatitis
Loss of hearing/Ringing in the ears
Eyesight problems
Nervous or mental conditions (including anxiety,
depression, sever or abnormal stress reaction
Any form of cancer
Any form of liver or gallbladder disease (including Hepatitis)
Any Blood disease
Sleep Disorders
Any Other Health problems not mentioned above
SECTION C: OCCUPATIONAL EXPOSURE
Yes

No

Details

Yes

No

Details

Do you have any current /active workers Compensation

Claim?
Have you had any Work Related Incapacity that has
resulted in you being way from work for more than 2
weeks in the last 2 years?
SECTION D: TB QUESTIONAIRRE
Clinical History Please provide information below if
you have any of the following symptoms
Cough for longer than 2 weeks
Haemoptysis (coughing blood)
Fever / Chills
Night sweats
Fatigue / Weakness
Anorexia
Unexplained weight loss

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Have you ever been in contact with a person known to

have TB, ie family, friends?
Have you ever had TB Screening before

I declare that the information I have provided is correct

Name
Signature
Date
SECTION E: VACCINATION SECTION

Type

Vaccine given this

consult date
(Yes/No)

Evidence of previous
vaccination or seroconversion (please
attach)

Date of next
booster

Declined by the
individual

Polio
DTP
Hepatitis A
Hepatitis B
Influenza
MMR
Varicella
Typhoid
Doctors Name
..
Clinic Name
..
Address
..
Signature and Date
..

Stamp or Seal (IF APPLICABLE)

If any vaccinations are declined please ensure Vaccination declination form is completed and attached.

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Vaccination Declination
(Complete only if applicant is not agreeable to complete Vaccinations)
Name
Gender

Date of Birth
Address
Male
Female

Phone
Number

First Name

State

Last Name

Address

State
Phone number

Please indicate which vaccines you wish not to receive

Type
Declined by the individual
Hepatitis A

Date

Hepatitis B
Influenza
MMR
Polio
Varicella

Declaration
I acknowledge that as part of my employment with International SOS, it is a recommended
that I be vaccinated against the above diseases.
I have chosen not to be vaccinated. I understand that this is at my own risk and that
Intl.SOS will not be held responsible for any disease or illness I should contract, whilst in
their employment.
I further understand that Intl.SOS may choose to restrict the facilities, at which I can work,
as a result of my refusal for vaccination.

.
Name (Please Print)

Signature

Date

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