MEDICAL SCREENING QUESTIONNAIRE
FOR FOOD SAFETY
FORM A
NAME:
EMP ID:
DESIGNATION:
DEPARTMENT:
Yes No
1.
2.
3.
4.
5.
6.
7.
8.
9.
Are you now, or have you over the last seven days, suffered from diarrhea / vomiting?
Have you suffered from fever since more than one week ago?
At present, are you suffering from:
i. skin trouble affecting hands, arms or face
ii. Boils, styes or septic finger
iii. discharge from eye, ear or gums/mouth
Do you suffer from:
i.
Recurring skin or ear infection
ii.
A recurring bowel disorder
In the last 5 days, have you been in contact with anyone who may have been suffering
from cholera?
In the last 7 days, have you been in contact with anyone who may have been suffering
from typhoid or paratyphoid?
In the last 7 days, have you been in contact with anyone who may have been suffering
from diarrhea or vomiting?
Have you ever had, or are you known to be a carrier of typhoid or paratyphoid?
Have you ever had, or are you known to have typhoid fever?
I declare that all above statements are true and complete to the best of my knowledge.
Signature employee
:…………………………
This form will be filled by the Nurse.
Date
:..…………..………………
FORM B (This form will be filled by the Doctor)
SECTION I : PHYSICAL EXAMINATION FOR FOOD SAFETY
Yes No
1. Fever
2. Jaundice
3. Skin infection on hands, arms, face
4. Boils, styes or septic finger
5. Discharge from eye, ear or gums/mouth
6. Typhoid vaccination status
SECTION II: LABORATORY TEST
RESULT
Positive Negative
1. Stool DR for ova & cysts
2. Other tests (if required)
Remarks
FITNESS STATUS
I hereby confirm that Mr/Ms/Mrs………………………………………. EMP ID ........................ had undergone
the medical examination and found to be:
i. Healthy and fit to work as food handler
ii. Unhealthy and not fit to work as food handler
iii. Unhealthy but can return to work on ……………….
Signature
Name
:
:
Registration number
Date
:
: