Medical Examinatuin For Driving License

EXAMINATION NO. EXAMINATION DATE:
PATIENT NAME: EMPLOYEE ID:
Age. GENDER
BLOOD GROUP: DESIGNATION:
DIVISION DEPARTMENT
UTE: Contact:
1) Identification Mark
2) Identification Mark
HEIGHT WEIGHT
BMI BP
PULSE DISTANCE VISION RT EYE
DISTANCE VISION LT EYE NEAR VISION RT EYE
NEAR VISION LT EYE COLOR VISION AS PER (ISHIHARA CHART)

Declaration:

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Yes No
क्रमांक कृपया नीचे दिये गए प्रश्न के उत्तर हाँ या ना मे दीजिये हां/नहीं Sr.No Please answer the questions in Yes or No Yes/No Observation and remark क्रमांक / Sr.No कृपया नीचे दिये गए प्रश्न के उत्तर हाँ या ना मे दीजिये / Please answer the questions in Yes or No हां/नहीं / Yes/No Observation and remark
/ Yes No

(Signature Of Individual)

Medical Fitness Certificate
This is certifying that I have personally examined the applicant
(i) that while examining the applicant I have directed special attention to his/her distant vision.
(ii) while examining the applicant, I have directed special attention to his/her hearing ability,
the condition of the arms, legs, hands and joints of both extremities of the applicant.
(iii) I have personally examined the applicant for reaction time, side vision, and therefore I certify that, to the best of my judgment, he is medically FIT UNFIT Unhealthy but can return to work after to hold a driving license.
(Name of Medical Assistant )
(Name of Medical Assistant)
(Factory Medical Officer)
(Factory Medical Officer )