Welcome to MSPL-PERSONNEL CERTIFICATION BODY

Name on Certificate *

Enrollment No

Date of Birth * Invalid Date.

Address

1.	Do you have any family history of :	Yes/No
	a) Heart ailnment
	b) Diabetes
	c) Mental illness
	d) Tuberculosis
2.	Whether you have undergone any surgical operatioin in the past?
3.	Do you take medicines regulrary?
4.	Do you have any body deformity or defect?
5.	Do you have any probklem of Rheumatism/Asthma/Joint pain?
6.	Do you have any large veins in your legs, thighs(varicose-veins)?
7.	Are you color blind?
8.	Do you have any hearing problem?
9.	Have you ever had any skin disorder?
10.	Have you ever had medical treatment for?
	a) Allergies
	b) Hay fever
	c) Reaction to surgery
	d) Reaction to medicine
	e) Sprain
	f) Fracture or broken bone
	g) Diabetes
	h) Fits
	i) Eye trouble
	j) Fainting spells
	k) Heart trouble
	l) Herina or Rupture
	m) Injury to knee joints
	n) Paralysis or weakness in arms or legs
	o) Emotional upsets
	p) Tuberculosis (TB)
	q) Rheumatism
	r) Prolonged fever
	s) Back pain
	t) Sacroiliac
	u) Any other health condition

Agree

SQPISEG

PRE-MEDICAL INFORMATION