Declaration: I confirm that the information above is true to the best of my knowledge and that any falsification of the information provided may potentially lead to disciplinary action against me.
Anxiety/stress/depression/other psychiatric illness Back problems Other musculoskeletal problems Cold/cough/flu-influenza Asthma Chest and respiratory problems Headache/migraine Benign and malignant tumours, cancer Blood disorders Heart, cardiac and circulatory problems Burns, poisoning, frostbite, hypothermia
Ear, nose and throat (ENT) Dental and oral problems Eye problems Endocrine/glandular problems Infectious diseases Injury, fracture Nervous system disorders Pregnancy related disorders Skin disorders Substance abuse
Notes: A copy of this form must be kept on the personnel file