$value) { ${"checkId" . ($index + 1)} = $value; } $sql_get_id_key1 = "SELECT * FROM checkup_form_key_value WHERE checkup_form_id = $checkId1"; $result_get_re_key1 = mysqli_query($conn, $sql_get_id_key1); error_log("dipak" . $sql_get_id_key1); while ($row_key_value1 = mysqli_fetch_assoc($result_get_re_key1)) { $dataArray1[$row_key_value1['checkup_form_key']] = $row_key_value1['checkup_form_value']; } $exa_date1 = getFieldFromTable('checkup_date', 'checkup_form', 'checkup_id', $checkId1); if ($exa_date1) { $examination_date1 = date("d-m-Y", strtotime($exa_date1)); } $sql_get_id_key2 = "SELECT * FROM checkup_form_key_value WHERE checkup_form_id = $checkId2"; $result_get_re_key2 = mysqli_query($conn, $sql_get_id_key2); error_log("dipak" . $sql_get_id_key2); while ($row_key_value2 = mysqli_fetch_assoc($result_get_re_key2)) { $dataArray2[$row_key_value2['checkup_form_key']] = $row_key_value2['checkup_form_value']; } $exa_date2 = getFieldFromTable('checkup_date', 'checkup_form', 'checkup_id', $checkId2); if ($exa_date2) { $examination_date2 = date("d-m-Y", strtotime($exa_date2)); } $sql_get_id_key3 = "SELECT * FROM checkup_form_key_value WHERE checkup_form_id = $checkId3"; $result_get_re_key3 = mysqli_query($conn, $sql_get_id_key3); error_log("dipak" . $sql_get_id_key3); while ($row_key_value3 = mysqli_fetch_assoc($result_get_re_key3)) { $dataArray3[$row_key_value3['checkup_form_key']] = $row_key_value3['checkup_form_value']; } $exa_date3 = getFieldFromTable('checkup_date', 'checkup_form', 'checkup_id', $checkId3); if ($exa_date3) { $examination_date3 = date("d-m-Y", strtotime($exa_date3)); } $sql_get_id_key4 = "SELECT * FROM checkup_form_key_value WHERE checkup_form_id = $checkId4"; $result_get_re_key4 = mysqli_query($conn, $sql_get_id_key4); error_log("dipak" . $sql_get_id_key4); while ($row_key_value4 = mysqli_fetch_assoc($result_get_re_key4)) { $dataArray4[$row_key_value4['checkup_form_key']] = $row_key_value4['checkup_form_value']; } $exa_date4 = getFieldFromTable('checkup_date', 'checkup_form', 'checkup_id', $checkId4); if ($exa_date4) { $examination_date4 = date("d-m-Y", strtotime($exa_date4)); } $sql_get_id_key5 = "SELECT * FROM checkup_form_key_value WHERE checkup_form_id = $checkId5"; $result_get_re_key5 = mysqli_query($conn, $sql_get_id_key5); error_log("dipak" . $sql_get_id_key5); while ($row_key_value5 = mysqli_fetch_assoc($result_get_re_key5)) { $dataArray5[$row_key_value5['checkup_form_key']] = $row_key_value5['checkup_form_value']; } $exa_date5 = getFieldFromTable('checkup_date', 'checkup_form', 'checkup_id', $checkId5); if ($exa_date5) { $examination_date5 = date("d-m-Y", strtotime($exa_date5)); } $sql_get_id_key6 = "SELECT * FROM checkup_form_key_value WHERE checkup_form_id = $checkId6"; $result_get_re_key6 = mysqli_query($conn, $sql_get_id_key6); error_log("dipak" . $sql_get_id_key6); while ($row_key_value6 = mysqli_fetch_assoc($result_get_re_key6)) { $dataArray6[$row_key_value6['checkup_form_key']] = $row_key_value6['checkup_form_value']; } $exa_date6 = getFieldFromTable('checkup_date', 'checkup_form', 'checkup_id', $checkId6); if ($exa_date6) { $examination_date6 = date("d-m-Y", strtotime($exa_date6)); } $sql_get_id_key7 = "SELECT * FROM checkup_form_key_value WHERE checkup_form_id = $checkId7"; $result_get_re_key7 = mysqli_query($conn, $sql_get_id_key7); error_log("dipak" . $sql_get_id_key7); while ($row_key_value7 = mysqli_fetch_assoc($result_get_re_key7)) { $dataArray7[$row_key_value7['checkup_form_key']] = $row_key_value7['checkup_form_value']; } $exa_date7 = getFieldFromTable('checkup_date', 'checkup_form', 'checkup_id', $checkId7); if ($exa_date7) { $examination_date7 = date("d-m-Y", strtotime($exa_date7)); } $sql_get_id_key8 = "SELECT * FROM checkup_form_key_value WHERE checkup_form_id = $checkId8"; $result_get_re_key8 = mysqli_query($conn, $sql_get_id_key8); error_log("dipak" . $sql_get_id_key8); while ($row_key_value8 = mysqli_fetch_assoc($result_get_re_key8)) { $dataArray8[$row_key_value8['checkup_form_key']] = $row_key_value8['checkup_form_value']; } $exa_date8 = getFieldFromTable('checkup_date', 'checkup_form', 'checkup_id', $checkId8); if ($exa_date8) { $examination_date8 = date("d-m-Y", strtotime($exa_date8)); } $sql_get_id_key9 = "SELECT * FROM checkup_form_key_value WHERE checkup_form_id = $checkId9"; $result_get_re_key9 = mysqli_query($conn, $sql_get_id_key9); error_log("dipak" . $sql_get_id_key9); while ($row_key_value9 = mysqli_fetch_assoc($result_get_re_key9)) { $dataArray9[$row_key_value9['checkup_form_key']] = $row_key_value9['checkup_form_value']; } $exa_date9 = getFieldFromTable('checkup_date', 'checkup_form', 'checkup_id', $checkId9); if ($exa_date9) { $examination_date9 = date("d-m-Y", strtotime($exa_date9)); } $sql_get_id_key10 = "SELECT * FROM checkup_form_key_value WHERE checkup_form_id = $checkId10"; $result_get_re_key10 = mysqli_query($conn, $sql_get_id_key10); error_log("dipak" . $sql_get_id_key10); while ($row_key_value10 = mysqli_fetch_assoc($result_get_re_key10)) { $dataArray10[$row_key_value10['checkup_form_key']] = $row_key_value10['checkup_form_value']; } $exa_date10 = getFieldFromTable('checkup_date', 'checkup_form', 'checkup_id', $checkId10); if ($exa_date10) { $examination_date10 = date("d-m-Y", strtotime($exa_date10)); } // $Array_a = array(); // $i =0; // foreach ($checkupIdsArray as $checkupFormId) { // $sql_get_id_key = "SELECT * FROM checkup_form_key_value WHERE checkup_form_id = $checkupFormId"; // $result_get_re_key = mysqli_query($conn, $sql_get_id_key); // // error_log("dipak".$sql_get_id_key); // while ($row_key_value = mysqli_fetch_assoc($result_get_re_key)) { // $dataArray[$row_key_value['checkup_form_key']] = $row_key_value['checkup_form_value']; // array_push($Array_a, $dataArray); // // error_log($dataArray.$i[$row_key_value['checkup_form_key']]." sumit"); // } // $Array_b[$checkupFormId]= $Array_a; // array_push($Array_c,$Array_b) ; // // error_log(print_r($Array_a,true)); // // error_log(print_r($Array_b,true)); // error_log("Dushant Maui ".print_r($Array_c,true)); // } ?>

(1)

Name: Code No.:
Date of Birth: Blood GR:
Plant Department: _________________________________________________
Designation: Date of Joining:
Residential Address:
_______________________________________________________________________
__________________________________ Tel No.
_______________________________________________________________________

IN CASE OF SERIOUS ACCIDENT PLEASE INFORM

_________________________________________________________
_________________________________________________________
_________________________________________________________
___________________________________________________________________________________
Identification Mark:
Allergy:


PERSONAL HISTORY

PERSONAL HISTORY: Marital Status:
NO. OF CHILDREN: MALE: FEMALE:
DIET:
SMOKING: SINCE:
TOBACCO CHEWING/PAN/GUTKHA: SINCE:
ALCOHOL: SINCE:
Remarks :

HISTORY OF MAJOR ILLNESS/OPERATION/ACCIDENT

,
___________________________________________________________
___________________________________________________________

(2)

FAMILY HISTORY OF Since Father Mother Siblings
1. Asthma
2. Diabetes
3. Hypertension
4. Allergy
5. I. H. D.
6. Tuberculosis
7. Other Other: Since:

FOR FEMALE CANDIDATES ONLY:

Year
1. Excessive or irregular Menstrual periods
2. Lump in the Breast
3. Gynaec Surgery
4. Any complications during Pregnancy
5. Whether on Oral Pills
6. Copper - T

Year
1. Excessive or irregular Menstrual periods
2. Lump in the Breast
3. Gynaec Surgery
4. Any complications during Pregnancy
5. Whether on Oral Pills
6. Copper - T

Year
Eyes D N D N D N D N D N
Rt
Lt
Year
Rt
Lt

COLOUR VISION:

(3)

GENERAL EXAMINATION

Date
Year
Age Yrs
Height in Cms
Weight in Kgs.
BMI
ABD - Girth
ENT
Teeth
Tongue / Oral Cavity
Skin
Nails
Thyroid
Lymph Glands
Deformities
Genito Urinary System
Hernia
Hydrocele
Piles
Systemic Examination
Pulse/Min.
BP mm of Hg.
C. V. S.
Abdomen
Resp. System
C.N.S.

(4)

INVESTIGATIONS

Date
YEAR
Routine Blood Examination
a. Haemoglobin gms. %
b. Total White Blood Cells
c. E.S.R. mm 1st Hour
CRP
I. Polymorphs
II. Eosinophils
III. Basophils
IV. Lymphocytes
V. Mononcytes
Routine Urine Examination
I. Albumin
II. Sugar
Microscopic Examination
I. Pus Cells
II. Crystals
IV. Red Blood Cells
Others
Routine Stool Examination
a. Ova
b. Cyst
c. Others
BLOOD CHEMISTRY AND SEROLOGY
a. (F) Blood Sugar
b. (PP). Blood Sugar
c. (R) Blood Sugar
d. HbA1C (Glycoselated Hb)
e. S. Creatinine
f. Serum Cholesterol

(5)



DATE
YEAR
g. S. Triglycerides
h. H.D.L.
I. L.D.L.
TC/HDL
LDL/HDL
k. S.G.PT.
S. Bilirubin (T)
(D)
I. Uric Acid
T3
T4
TSH
Vit. D
Vit. B12
PSA: Total
PSA: Free
Ratio:
X Ray Chest:

(6)


ECG

USG

(7)


Year
Pulmonary Function Test FVC
FEV 1 % % % % %
FEV1/FVC % % % % %
MMF (FEF 25-75%) % % % % %
PEFR L L L L L
Result

Year
Pulmonary Function Test FVC
FEV 1 % % % % %
FEV1/FVC % % % % %
MMF (FEF 25-75%) % % % % %
PEFR L L L L L
Result

(8)

YEAR Complaints during Annual Medical Check up Remedial Measures Taken Signature of Medical Advisor

(9)


RECORD OF LONG SPELLS OF SICKNESS

Period of Sickness Date of resumption of duty Diagnosis/Treatment Name of treating Doctor

(10)


RECORD OF INDUSTRIAL / NON INDUSTRIAL ACCIDENTS

Date Ref. No. of Accident with date Time Nature of Injury No. of days. away from work Treatment Name of treating Doctor

(11)


DAILY CASE PAPER

Date Clinical Notes Advised Treatment/ Inv. / Ref. Leave Doctor's Initials

(25)


HYPERTENSION

DATE BLOOD PRESSURE Wt.in Kg. Treatment
mm of Hg

(26)


HYPERTENSION

DATE BLOOD PRESSURE Wt.in Kg. Treatment
mm of Hg

(27)


DIABETES MELLITUS

DATE Wt. BLOOD SUGAR Glycoselated Hb Treatment
Fasting Post Prandial

(28)


DIABETES MELLITUS

DATE Wt. BLOOD SUGAR Glycoselated Hb Treatment
Fasting Post Prandial