PRE-PLACEMENT MEDICAL EXAMINATION FOR EMPLOYEES HANDLING
(NITRO AMINO COMPOUND)

NAME:- ________________________ Date :-
CODE NO :- CATEGORY :-
AGE :- SEX :- DEPT :-

GENERAL EXAMINATION
Body Temp :- ________ Spo2 :- ______ % Pulse :- ________ /Min
BP :- _________ mm of hg Weight :- ________ Kg
Tongue :- _________ Nail :- ________

BLOOD EXAMINATION
Investigations :
Hb :- _________ gm% G6PD :- ________ UgHB%


Remarks:
1. MEDICALLY FIT TO WORK lN ANILINE (NITRO AMINO COMPOUND)
PLANT- _____
1. MEDICALLY UNFIT TO WORK lN ANILINE (NITRO AMINO COMPOUND)
PLANT- _____ BECAUSE OF

Factory Medical Officer
SR.NO DATE TIME COMPLAINTS SPO2 NAILS TONGUE REMARKS