MEDICAL EXAMINATION FOR FOOD HANDLERS

Name: .......................................................................................
Nationality: ...............................................................................
Address:............................................................................................................................
..........................................................................................................................................
.................................................................................................................................
Home Contact no/Work Place Contact no: ....................................................................
A. Declaration Form (to be completed b !ood "andler# $e% &No
1 Are you now, or have you over the last seven days, suffered from diarrhoea/vomitin.
! Have you suffered from fever since more than one week ao"
# At $resent, are you sufferin from:
i. %kin trou&le affectin hands, arms or face
ii. 'oils, styes or se$tic finer
iii. (ischare from eye, ear or ums/mouth
) (o you suffer from:
i. *ecurrin skin or ear infection
ii. A recurrin &owel disorder
+ ,n the last + days, have you &een in contact with anyone who may have &een sufferin from
cholera"
- ,n the last . days, have you &een in contact with anyone with diarrhoea or vomitin"
. ,n the last !1 days have you &een in contact with anyone who may have &een sufferin from
ty$hoid or $araty$hoid"
/ Have you ever had, or are you now known to &e a carrier of ty$hoid or $araty$hoid"
0 Have you ever had, or are you now known to have ty$hoid fever"
, declare that all the a&ove statements are true and com$lete to the &est of my knowlede.
%inature: 1111111111111. (ate: 11111111111
Witnessed &y: 111..............%inature: 1111111111111..
(ate: 1111111
'. ("%ical E)amination (To be completed b doctor # $e%&No
* 2ever
+ 3aundice
, %kin infection on hands, arms, face
- 'oils, styes or se$tic finer
. (ischare from eye, ear or ums/mouth
C. Laborator Te%t
*esult
1. %tool culture 4if re5uired6 Positive /Neative
a. 7y$hoid
&. Cholera
!. 8ther tests 4if re5uired6
Note:
Medical examination should be conducted annually by a registered medical practitioner. However, at
any time a certified food handler should undergo re-examination if these conditions arise:
a. Jaundice
b. iarrhoea
c. !omiting
d. "ever
e. #ore throat with fever
f. !isibly infected s$in lesions %boils, cut, etc&
g. ischarges from the ear, eye or nose.
'he association should ensure that those who suffer from any of the above conditions are excluded
from handling food and be re-examined by a registered medical practition
SHIBU VARGHESE
DR SHIBU VARGHESE M.B.B.S, M.S (ORTHO), F.A.J.R. (GER), F.H.A (GER)
HEAD OF SPORTS MEDICINE & SCIENCE
(ERFORMA FOR MEDICAL FITNESS CERTIFICATE FOR FOOD
HANDLERS
428* 7H9 :9A* ......................6 4%ee Para No. 1;.1.!, Part< ,,, %chedule < ) of 2%%
*eulation, !;116
,t is certified that %hri/%mt./=iss.................................................................... em$loyed
with =/s.............................................................................., comin in direct contact with
food items has &een carefully e>amined? &y me on date....................
'ased on the medical e>amination conducted, he/she is found free from any infectious
or communica&le diseases and the $erson is fit to work in the a&ove mentioned food
esta&lishment.

Name and Si/nat0re 1it"
Seal
8f *eistered =edical Practitioner /
Civil %ureon
2Medical E)amination to be cond0cted3
1. Physical 9>amination
!. 9ye 7est
#. %kin 9>amination
). Com$liance with schedule of @accine to &e inoculated aainst enteric rou$ of diseases
+. Any test re5uired to confirm any communica&le or infectious disease which the $erson
sus$ected to &e sufferin from on clinical e>amination.