MEDICAL CENTRE

PRE - EMPLOYMENT MEDICAL EXAMINATION FORM FOR CONTRACT EMPLOYEES.

NAME:

C/o. _____________________________

Age:

Sex:

	Present History of Illness
	_________________________________
	_________________________________

Present History:	Smoking:	marital Status:
	Alcohol:
	Tobacco Chewing:
	Others:

Past History:	H/o. Major illness:
	H/o. Any Accident:
	H/o. Any Major Operation:

Family History:

Has anyone in the family suffered / suffering from

Diseases	Yes	No
Diabetes
Hypertension
Bronchial Asthma
Heart Diseases
Tuberculosis
Remarks :

GENERAL EXAMINATION

1. Height :	2. Weight :
3. Built : Muscular Normal Thin	4. E.N.T. :
5. Teeth :	6. Tongue :
7. Nails :	8. Conjunctiva :
9. Skin :	10. Lymph Nodes :
11. Thyroid Gland :	12. Deformities :

Eyes	Distant		Near
Eyes	R	L	R	L
Uncorrected
Corrected

Genito Urinary System :

Hernia:	Hydrocele:	Vericocele:
Remarks :

SYSTEMIC EXAMINATION:

1. Cardio vascular system:	Pulse / min.	Blood pressure _mm of Hg
	Heart sounds	murmurs _
	Spo2
Cardio vascular Remarks:

Respiratory System Shape of Chest Chest Movements Trachea Breath Sounds Abnormal Sounds		Abdomen Liver Spleen Ascites Any Lumps
Central Nervous System Higher Functions Cranial Nerves Sensory System Motor Functions Reflexes		Locomotor System Posture Gait Spine

Remarks:

MEDICAL ADVISOR