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MAIHAR IU | Department | OCCUPATIONAL HEALTH CENTRE |
| Document No. | F-MED-08 | ||
| Revision | 0.0 | ||
| Implementation Date | 01.04.2016 | ||
| Initial Medical Examination Card (Short Term) | |||
| Serial No | |||||
| Name | |||||
| Father Name | |||||
| Age/Sex | diff ( $to )->y; if ($gender == 'M') echo " Male"; elseif ($gender == 'F') echo " Female"; ?> | ||||
| Grade/Post | |||||
| Mobile.No. | |||||
| Gate pass No./P No | Date | ||||
| TO BE FILLED IN BY THE CANDIDATE | |||||
| name="history_param" value=""> | |||||
Signature /Left Thumb Impression of Candidate |
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| RECORD OF MEDICAL EXAMINATION | |||||
| Height(cms) | CLINICAL EXAMINATION | ||||
| Weight(kgs) | PALLOR | ||||
| PULSE | |||||
| Vision | BP | mm of Hg | |||
| RT.EYE | LT.EYE | CVS | |||
| Distant Vision | Without Glasses | 6/ | 6/ | RS | |
| With Glasses | 6/ | 6/ | MUSCULO SKELETAL | ||
| Near Vision | Without Glasses | N/ | N/ | ANY OTHER RELEVANT FINDING | |
| With Glasses | N/ | N/ | |||
| IDENTIFICATION OF INDIVIDUAL COLOURS | |||||
| COLOR VISION | |||||
| OPINION/ REMARKS (BY MEDICAL ASSISTANT) | |||||
| OPINION/ REMARKS (BY DOCTOR) | |||||
| Signature of Medical Assistant |
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SIGNATURE OF MEDICAL OFFICER (WITH STAMP) |
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