MEDICAL EXAMINATION REPORT - CANTEEN EMPLOYEES

Date of Pre-employment Medical Exam: Sr. No.
Name:
Address:
Natural Job In Canteen:
Marital Status:
No. of children:
Family Plannig History:
Diet: Smoking/Tobacco : Since:

Alcohol:
Yes No
H/o. Diarrhoea/Vomiting, Fever during Last Seven Days checked type="checkbox" name="" id=""> checked type="checkbox" name="" id="">
H/o. Boils/Styes/Septic Fingers At Present checked type="checkbox" name="" id=""> checked type="checkbox" name="" id="">
H/o. Skin/Ear Infection in the past checked type="checkbox" name="" id=""> checked type="checkbox" name="" id="">
H/o. Contact with person having Jaundice/Typhoid during last 3 weeks. checked type="checkbox" name="" id=""> checked type="checkbox" name="" id="">

GENERAL EXAMINATION

DATE:
AGE
HEIGHT cms
WEIGHT Kg
FEVER
JAUNDICE
SKIN INFECTION ON HANDS, ARMS, FACE
BOILS, STYES OR SEPTIC FINGER
DISCHARGE FROM EYE, EAR OR GUMS/MOUTH
HERNIA
HYDROCELE
YEAR
EYES D N
Rt
Lt

SYSTEMIC EXAM DATE:
PULSE /min
BP mm of Hg
CVS
ABDOMEN
RESP SYSTEM
C.N.S.
INVESTIGATIONS
Hb gm %
TLC
ESR mm
Polymorphs
Lymphocytes
Eosinophils
Monocytes
Basophils
BLOOD SUGAR (R)
SGPT
WIDAL TEST
ANTI HAV-IgM
HIV TEST
Stool Examination
X-Ray Chest

TYPHOID VACCINATION DATE: Batch No
Deworming Date
I hereby confirm that Mr./Ms./Mrs had undergone
medical examination and found to be:
1. Healthy and fit to work as food handlers
2. Unhealthy and not fit to work as food handler
3. Unhealthy but can return to work on
...........................


Date:
Registration Number :
Medical Officer:...................