| MAIHAR IU | Department | OCCUPATIONAL HEALTH CENTRE | |
| Document No. | F-MED-09 | ||
| Revision | 0.0 | ||
| Implementation Date | 01.04.2016 | ||
| Initial Medical Examination Card (LongTerm) | |||
| SR.NO. | {$serial_no} | ||||
| NAME | {$patient_name} | ||||
| FATHER NAME | {$father_name} | ||||
| AGE/SEX | {$age} {$gender} | ||||
| ADDRESS | {$address} | ||||
| GRADE/POST | {$designation_name} | ||||
| MOBILE.NO. | {$primary_phone} | ||||
| GATE PASS NO./P NO | {$emp_code} | DATE | {$medical_entry_date} | ||
| TO BE FILLED IN BY THE CANDIDATE | |||||
| 9.HISTORY PAST AND PRESENT ILLNESS [ if YES write √ if NO write X ] | 10. PAST OCCUPATIONAL HISTORY | ||||
| NAME OF ORGANIZATION | TRADE/DESIGNATION | PERIOD OF SERVICE- IN YEARS | PAST OCCUPATIONAL ILLNESS | {$row_past_occupational_history['org_name']} | {$row_past_occupational_history['trade_designation']} | {$row_past_occupational_history['period_services']} | {$row_past_occupational_history['past_occu_illness']} | EOD; } }else{ $txt.=<<
| 11.PERSONAL INFORMATION | EOD; $sql_patient_personal_info=" select * from patient_personal_information where medical_exam_id='".$_REQUEST['medical_exam_id']."' "; $result_patient_personal_info = mysqli_query($conn,$sql_patient_personal_info); $row_patient_personal_info= mysqli_fetch_assoc($result_patient_personal_info); @extract($row_patient_personal_info); $date_of_exam=strtoupper(date_format(date_create($row_patient_personal_info['date_of_exam']),"d-M-Y ")); $txt.=<<I. DATE OF BIRTH | {$dob} | |||
| II. IDENTIFICATION MARK | {$identi_mark} | ||||
| III. DATE OF EXAMINATION | {$date_of_exam} | ||||
| IV. MARRIED/UNMARRIED | {$marital_status} | ||||
| V. NO. OF CHILDREN | {$no_of_child} | ||||
| VI. WHETHER ADOPTING ANY METHOD OF FAMILY PLANNING | {$adopting_family_planning} | ||||
| VII. SMOKING / TOBACCO / ALCOHOL | {$addiction} | ||||
| 12.DECLARARTION:
CERTIFIED THAT THE PARTICULARS GIVEN BY ME IN THE FOREGOING ABOVE ARE TRUE, COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. IF ANY OF THIS INFORMATION IS FOUND TO BE FALSE/INCOMPLETE/ INCORRECT, ONLY I SHALL BE RESPONSIBLE FOR IT AND COMPANY HAVE FULL RIGHT TO CANCEL MY APPOINTMENT OR TERMINATE MY SERVICE CONTRACT. मैं अपने पूरे होशोहवाश में यह प्रमाणित करता हूँ कि मेरे द्वारा दी गयी उपरोक्त समस्त जानकारी पूर्णत सही है, अगर मेरे द्वारा दी गयी कोई जानकारी गलत पाई जाती है तो उसके लिए पूर्णत मैं जिम्मेदार हूं एवं कंपनी को यह अधिकार है कि वो मुझे नौकरी में न रखे अथवा मेरी सेवाओं को समाप्त कर दे SIGNATURE/LEFT THUMB IMPRESSION OF CANDIDATE DATE |
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| RECORD OF MEDICAL EXAMINATION | |||||
| Height(cms) | {$height} | WAIST(cms) | {$waist} | CLINICAL EXAMINATION | |
| WEIGHT(kgs) | {$weight} | HIP(cms) | {$hip} | NAILS | {$nails} |
| BMI(cms) | {$bmi} | PULSE | {$pulse} | ||
| VISION | BP | {$bp} MM OF HG | |||
| RT.EYE | LT.EYE | ABDOMEN | |||
| DISTANT VISION | WITHOUT GLASSES | 6/{$dis_without_right_eye} | 6/{$dis_without_left_eye} | LIVER | {$liver } |
| WITH GLASSES | 6/{$dis_with_right_eye} | 6/{$dis_with_left_eye} | Speen | {$speen } | |
| NEAR VISION | WITHOUT GLASSES | N/{$near_without_right_eye} | N/{$near_without_left_eye} | TENDERNESS | {$tenderness } |
| WITH GLASSES | N/{$near_with_right_eye} | N/{$near_with_right_eye} | ANY OTHER ABNORMALITY | {$any_other_abnormality } | |
| SKIN | {$skin } | ||||
| COLOR VISION | {$color_vision } | RS | {$rs } | ||
| CVS | MUSCULO SKELETAL | {$musculo_skeletal } | |||
| S1 | {$s1} | S2 | {$s2} | CNS | {$cns } |
| ANY OTHER SOUND | {$any_other_sound} | ECG (12 LEAD) FINDINGS | {$ecg_findings} | ENT | |
| 2D ECHO/TMT FINDINGS | {$tmt_findings} | Conversational Hearing | {$conversational_hearing } | ||
| AUROSCOPY | {$auroscopy } | ||||
| EAC | {$eac } | ||||
| NOSE | {$nose } | ||||
| THROAT | {$throat } | ||||
| 14. ILO CLASSIFICATION OF CHEST RADIOGRAPH (Enclosed Chest Radiograph) | |||||
| PROFUSION OF PNEUMOCONIOTIC OPACITIES | GRADES | Types | |||
| {$profusion_opacities} | {$grade} | {$type} | |||
| RESULT OF SPIROMETRY (REPORT ENCLOSED) | |||||
| PARAMETERS | PREDICTED VALUE | PERFORMED VALUE | % OF PREDICTED | ||
| FORCED VITAL CAPACITY (FVC) | {$fvc_pre} | {$fvc_post} | {$fvc} | ||
| FORCED EXPIRATORY VOLUME IN 1 SEC (FEV1) | {$fev1_pre} | {$fev1_post} | {$fev1} | ||
| FEV1/FVC | {$fev1_fvc_pre} | {$fev1_fvc_post} | {$fev1_fvc} | ||
| PEAK EXPIRATORY FLOW | {$peak_expiratory_flow_pre} | {$peak_expiratory_flow_post} | {$peak_expiratory_flow} | ||
| AUDIOMETRY FINDINGS ( REPORT ENCLOSED) | |||||
| CONDUCTION TYPE | LEFT EAR | RIGHT EAR | |||
| AIR CONDUCTION | {$air_cond_left} | {$air_cond_right} | |||
| BONE CONDUCTION | {$bone_cond_left} | {$bone_cond_left} | |||
| INVESTIGATIONS | |||||
| BLOOD GROUP {$blood_group} | |||||
| HB | {$hb} | TLC | {$tlc} | DLC-N | {$dlc_n} |
| DLC-L | {$dlc_l} | DLC-M | {$dlc_m} | DLC-E | {$dlc_e} |
| ESR | {$esr} | S. UREA | {$s_urea} | S.CREATININE | {$s_creatinine} |
| BLOOD SUGAR | {$blood_sugar} | VDRL | {$vdrl} | HBSAG | {$hbsag} |
| HIV | {$hiv} | LIPID PROFILE | {$lipid_profile} | ||
| URINE RE/ME | |||||
| APPEARANCE | {$appearance} | PUS CELLS | {$pus_cells} | RBCS | {$rbcs} |
| EPITHELIAL CELLS | {$epithelial_cells} | OTHER RELEVANT FINDINGS | {$other_relevant_findings} | ALBUMIN | {$albumin} |
| SUGAR | {$sugar} | ||||
| STOOL RE/ME | {$stool_re_me} | ||||
| OPINION OF THE MO | {$opinion_mo} | ||||
| REMARKS BY MEDICAL ASSISTANT | {$opinion_remarks_medical_assistant} | ||||
| REMARKS BY DOCTOR | {$opinion_remarks} | ||||
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| DOCTOR NAME | {$doctor_name} | ||||
| QUALIFICATION | {$approving_doc_qualification} | ||||
| REGISTRATION NO | {$approving_doc_regd_no} | ||||