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MAIHAR IU | Department | OCCUPATIONAL HEALTH CENTRE |
| Document No. | F-MED-12 | ||
| Revision | 0.0 | ||
| Implementation Date | 01.04.2016 | ||
| Annual Medical Examination Card | |||
| Sr.No | |||
| Name | Father Name | ||
| Age/Sex | diff($to)->y; if($gender=='M') echo " Male"; elseif ($gender=='F') echo " Female"; ?> | Grade/Post | |
| Address | Mobile.No. | ||
| Gate pass No./P No | Date | ||
| Contractor Name | Department | ||
| HISTORY PAST AND PRESENT ILLNESS | |||
| ARE YOU ON ANY REGULAR MEDICATION (IF YES, PLEASE SPECIFY) | |||
| RECORD OF MEDICAL EXAMINATION | |||||
| Height(cms) | Waist(cms) | CLINICAL EXAMINATION | |||
| Weight(kgs) | Hip(cms) | NAILS | |||
| BMI(cms) | PULSE | ||||
| Vision | BP | mm of Hg | |||
| RT.EYE | LT.EYE | ABDOMEN | |||
| Distant Vision | Without Glasses | 6/ | 6/ | Liver | |
| With Glasses | 6/ | 6/ | Speen | ||
| Near Vision | Without Glasses | N/ | N/ | Tenderness | |
| With Glasses | N/ | N/ | Any other abnormality | ||
| SKIN | |||||
| COLOR VISION | RS | ||||
| MUSCULO SKELETAL | |||||
| S1 | S2 | CNS | |||
| Any other Sound | ECG (12 Lead) findings | ENT | |||
| 2D Echo/TMT Findings | Conversational Hearing | ||||
| AUROSCOPY | |||||
| EAC | |||||
| NOSE | |||||
| THROAT | |||||
| FINDINGS OF CHEST RADIOGRAPH | URINE RE/ME | ||||
| Appearance | |||||
| Pus cells | |||||
| RBCs | |||||
| STOOL RE/ME | Epithelial cells | ||||
| Other Rel. findings | |||||
| Albumin | |||||
| Sugar | |||||
| RESULT OF SPIROMETRY Findings | |||||
| Parameters | Value(Pre-medication) | Value(Post-medication) | |||
| Forced Vital Capacity (FVC) | |||||
| Forced Expiratory Volume in 1 sec (FEV1) | |||||
| FEV1/FVC | |||||
| Peak Expiratory Flow | |||||
| RESULT OF AUDIOMETRY FINDINGS | |||||
| Conduction Type | Left Ear | Right Ear | |||
| Air Conduction | |||||
| Bone Conduction | |||||
| INVESTIGATIONS | |||||
| Blood Group | |||||
| Hb | TLC | DLC-N | |||
| DLC-L | DLC-M | DLC-E | |||
| Platelets | S. Urea | S.Creatinine | |||
| Blood Sugar | ESR | BUN | |||
| Uric Acid | Acid Phosphatase | PSA | |||
| Lipid Profile | |||||
| Liver Function Test | |||||
| Thyroid Profile (Females) | |||||
| Dental Examination Report | |||||
| Findings of Mammography (Females) | |||||
| Findings of PAP Smear (Females) | |||||
| Any other Significant Finding | |||||
| Digital Signature By Medical Assistant |
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| Opinion/ Remarks (By Doctor) | |||||
| Signature of Medical Officer |
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| Doctor Name | |||||
| Qualification | |||||
| Registration No | |||||