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MAIHAR IU | Department | OCCUPATIONAL HEALTH CENTRE |
| Document No. | F-MED-13 | ||
| Revision | 0.0 | ||
| Implementation Date | 01.04.2016 | ||
| PERIODIC MEDICAL EXAMINATION (SHORT-TERM) | |||
| Serial No | |||||
| Name | Age/Sex | diff($to)->y; if($gender=='F') echo " FEMALE"; else echo " MALE"; ?> | |||
| Father Name | |||||
| Grade/Post | Mobile.No. | ||||
| Gate pass No./P No | Date | ||||
| TO BE FILLED IN BY THE CANDIDATE | |||||
| name="history_param" value="" > | |||||
| RECORD OF MEDICAL EXAMINATION | |||||
| Height(cms) | CLINICAL EXAMINATION | ||||
| Weight(kgs) | PALLOR | ||||
| PULSE | |||||
| Vision | BP | mm of Hg | |||
| RT.EYE | LT.EYE | CVS | |||
| Distant Vision | Without Glasses | 6/ | 6/ | RS | |
| With Glasses | 6/ | 6/ | MUSCULO SKELETAL | ||
| Near Vision | Without Glasses | N/ | N/ | ENT | |
| With Glasses | N/ | N/ | ABDOMEN | ||
| IDENTIFICATION OF INDIVIDUAL COLOURS | ANY OTHER RELEVANT FINDING | ||||
| COLOR VISION | Random Blood Sugar | ||||
| OPINION/ REMARKS (BY MEDICAL ASSISTANT) | |||||
| OPINION/ REMARKS (BY DOCTOR) | |||||
| Signature of Medical Assistant |
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| Signature of Medical Officer | |||||
| Doctor Name | |||||
| Qualification | |||||
| Registration No |