EMP CODE

SIX MONTHLY MEDICAL CHECK UP

Name:	DEPT.:
DESIGNATION:	BLOOD GROUP.:

: PERSONAL HISTORY:

MARITAL STATUS:
NO. OF CHILDREN :	MALE:	FEMALE:

F. P. HISTORY:

DIET:

SMOKING:	SINCE:
TOBACCO CHEWING/PAN/GUTKHA :	SINCE:
ALCOHOL:	SINCE:
Remarks:

HISTORY OF MAJOR ILLNESS/OPERATION/ACCIDENT:

DISEASE	FAMILY MEMBERS	SINCE
DIABETES
HYPERTENSION
BRONCHIAL ASTHMA
HEART DISEASE
TUBERCULOSIS

GENERAL EXAMINATION:

DATE
AGE (YEARS)
HEIGHT (cms)
WEIGHT (kgs)
ENT
DEFORMITIES
TEETH
TONGUE
NAILS
SKIN
EYES
	D	N	D	N	D	N	D	N
RT
LT
SYSTEMIC EXAMINATION
CVS
PULSE: (/min)
SPO2: (%)
BLOOD PRESSURE mm of Hg
HEART SOUNDS
MURMURS
PERIPHERAL PULSATIONS
GENITO URINARY
HERNIA
HYDROCELE
REMARKS
RESPIRATORY SYSTEM
SHAPE OF CHEST
CHEST MOVEMENTS
TRACHEA
BREATH SOUNDS
ABNORMAL SOUNDS
Remarks
LOCOMOTOR SYSTEM
POSTURE
GAIT
SPINE
ABDOMEN
LIVER
SPLEEN
ASCITIS
ANY LUMPS
REMARKS
CNS
HIGHER FUNCTIONS
CRANIAL NERVES
SENSORY SYSTEM
MOTOR FUNCTIONS
REFLEXES
REMARKS
INVESTIGATIONS
HEMOGLOBIN-gm%
TLC
ESR mm. 1st Hour
POLYMORPHS
LYMPHOCYTES
EOSINOPHILS
MONOCYTES
BASOPHILS
BLOOD SUGAR (R)-mg/dl
SGPT
SERUM CREATININE
METHAEMOGLOBIN
G6PD
URINE EXAMINATION
ALBUMIN
SUGAR
PUS CELLS
R.B.C.



PFT:	Report:
(Once in a year)	Observed				%
FVC (Liters)
FEVI (Liters)
FEV1/FVC ( % )
MMF (FEF 25-75%)
PEFR -PEFR (Liters)
X-RAY CHEST (Once in a year)
Remark & Advice

FMO