	MEDICAL EXAMINATION FOR CONFINED SPACE

	Sr No.
	Date:

NAME:

AGE:

SEX.

	PRESENT HISTORY OF ILLNESS

	____________________________________

PERSONAL HABITS:

SMOKING:

ALCOHOL:

TOBACCO CHEWING:

OTHERS:

HISTORY OF KNOWN ILLNESS	DM:	STROKE:	TB
	HTN:	TUMOR:	HEART DISEASE:
	EPILEPSY:	ASTHMA:	OTHERS:
	ACROPHOBIA (HEIGHT PHOBIA):

PAST HISTORY:

MAJOR ILLNESS :

ANY ACCIDENT :

ANY MAJOR OPERATION:

GENERAL EXAMINATION:

1. HEIGHT: cms	2. WEIGHT: kg	3. NAILS:
4. PULSE: /Min	5. B.P. : mm/Hg	6. DEFORMITY:
7. SPO2:

VISION:

Eyes	Distant		Near
Eyes	R	L	R	L
Uncorrected
Corrected

COLOUR VISION:

FIELD OF VISION:

A. CVS:
B. RESP SYSTEM :
C. ABDOMEN :
D. CNS:
TANDEM WALKING :	FINGER NOSE TEST :
ROMBERG'S TEST:	HIGHER FUNCTION:
GAIT:	SPINE:

INVESTIGATIONS

HAEMOGLOBIN : gram %

BLOOD GR:

RBS: mg/dL

Remarks: Medically

DATE	B.P	PULSE	SPO2	TEMP	FITNESS	SIGN
	/ mm of Hg	/ min	%	F

Factory Medical Officer