y; $company_name = getFieldFromTable('employer_contractor_name','employer_contractor','id',$row_for_fitness['visitor_company']); $host_person = getFieldFromTable('patient_name','patient_master','id',$row_for_fitness['visiting_patient_id']); $epilepsy = (strcmp($row_for_fitness['entry_med_epilepsy'],'yes')==0)?("YES"):("NO"); $diabetes = (strcmp($row_for_fitness['entry_med_diabetes'],'yes')==0)?("YES"):("NO"); $entry_med_ill = (strcmp($row_for_fitness['entry_med_ill'],'yes')==0)?("YES"):("NO"); $entry_med_aller = (strcmp($row_for_fitness['entry_med_aller'],'yes')==0)?("YES"):("NO"); $entry_med_medi = (strcmp($row_for_fitness['entry_med_medi'],'yes')==0)?("YES"):("NO"); $entry_med_reac = (strcmp($row_for_fitness['entry_med_reac'],'yes')==0)?("YES"):("NO"); ?>

OCCUPATIONAL HEALTH CENTRE

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FARMSON VISITOR’S HEALTH DECLARATION FORM
Run Time :




This medical form helps us to ensure a safe and healthy experience for you. We urge you to be completely thorough in providing us with the information requested. Information provided will be kept restricted and completely confidentiality of the details will be maintained.

Name:
Age:
Company:
HOST PERSON VISITING:
Date/Time:
EMERGENCY CONTACT NAME/ MOB. NUMBER:
Blood pressure:
SPO2:
Epilepsy:
Diabetes:



Medical Conditions:

If you have any medical condition(s) or illness, please provide details:
If Yes, please specify:


Do you have any allergies with Medicine or Chemical restrictions?
If Yes, please specify:


Are you on any Medication at the moment?
If Yes, please specify:


Do you have any Open wound/ Rash / Skin Reactions on your body?
If Yes, please specify:

Thank you for your cooperation:

Visitor’s signature / Date :
Checked By (Name) :
Signature / Date :