FORM 17
(Prescribed under Rule 68-T and 102)
(as amended vide Notification No.1183-LW-IR-1/91 dated 27th Nov.1991)
Health Register
1.Serial No. in the register of adult worker:
2.Name of worker:
3.Sex:
4.Date of Birth:

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Department/works Name of hazardous process Dangerous process/operation Nature of job/occupation Raw materials,products or by-products likely to be exposed to Date of joining Date of leaving/transfer other work Reason for discharge/transfer to other work
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Medical examination and the results there of
Signs and symptoms observed during examination
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CLINICAL EXAMINATION Date:

Height: cm            Weight: Kgs            BMI:            Built & Nutrition:            Blood Pressure: mmHg            Pulse: /m


General Inspection            A:                CY:                I:                Cl:                E:


Respiratory System:            Chest:                Chest Inspiration:                Expiration: cm (NA Female Candidate)               


SKIN:            Muscular Skeletal:               


CNS:            Speech:                Higher Function:                Motor Function:                Vertigo:               


Reflexes(Superficial & Deep):                Vibration syndrome:               


ENT:            Conversational Hearing:                EAC:                Nose:                Throat:               


Dental:                Teeth & Gum:               


CVS:                 S1 & S2:                     Any other sound:                    


ABDOMEN:            Liver:                          Spleen:                          Tenderness:                         


Any Other Abnormality:               

Medical examination and the results thereof 11
Nature of tests & results thereof Result Fit/Unfit
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BLOOD ROUTINE EXAMINATION Date:

Hemoglobin: % gm/dl            Total Leucocyte Count: cu. /mm           


Differential Leucocyte Count            Neutrophils: %                Lymphocytes: %                Monocytes: %                Eosinophil: %                Basophils: %


Total Cholesterol: mg/dl                (LDL) Cholesterol: mg/dl                (VLDL) Cholesterol : mg/dl               


Blood Sugar:                RBS: mg/dl                FBS: mg/dl                PPBS: mg/dl               


RENAL FUNCTION TEST                                        LIVER FUNCTION TEST                                       


Uric Acid: mg/dl                    Total Bilirubin mg/dl


Urea: mg/dl                    Conj. mg/dl


Creatinine: mg/dl                    Unconj. mg/dl


Sodium (Na+): mg/dl                    SGOT mg/dl


Potassium (K+): mg/dl                    SGPT mg/dl


Phosphate: mg/dl                    Alkaline Phosphatase mg/dl


Bi-Carbonate (Hco3): mmol/l                  Total Protein: g/dl


Globulin: g/dl


Albumin: g/dl


URINE RE & ME:


Pulmonary Function Test (Spirometry) :


Audiometry :


Chest X-Ray:


ECG :


Others:

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If declared unfit for work Signature with date of the Factory Medical Officer/ the Certifying Surgeon
Period of Temporary withdrawal from that work Reason for such withdrawal Date of declaring him unfit for that work Date of issuing fitness Certificate
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