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MAIHAR IU | Department | OCCUPATIONAL HEALTH CENTRE |
| Document No. | F-MED-11 | ||
| Revision | 0.0 | ||
| Implementation Date | 01.04.2016 | ||
| PERIODIC MEDICAL EXAMINATION CARD | |||
| Serial No | Name | ||
| Father Name | |||
| Age/Sex | diff($to)->y; if($gender=='M') echo " Male"; elseif ($gender=='F') echo " Female"; ?> | ||
| Dept./ Contractor Name | () | ||
| Tade | |||
| Mobile.No. | |||
| Gate pass No./P No | Date | ||
| TO BE FILLED IN BY THE CANDIDATE | |||
| name="history_param" value="" > | |||
| Present Complaint If any | |||
| Are you on any regular medication | |||
| RECORD OF MEDICAL EXAMINATION | |||||
| Height(cms) | BP | mm of Hg | |||
| Weight(kgs) | PULSE | ||||
| BMI | |||||
| Vision | |||||
| RT.EYE | LT.EYE | Findings of Chest Radiograph (done after every 03 year) | |||
| Distant Vision | 6/ | 6/ | |||
| Near Vision | N/ | N/ | ECG Findings | ||
| COLOR VISION | |||||
| RESULT OF SPIROMETRY Findings | |||||
| Parameters | Performed Value | Predicted Value | |||
| 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 | |||
| ESR | S. Urea | S.Creatinine | |||
| Blood Sugar | VDRL | ||||
| Urine RE/ME | |||||
| Albumin | Sugar | ||||
| Stool RE/ME | |||||
| OPINION/ REMARKS (BY DOCTOR) | |||||
| Signature/Left Thumb Impression of Employee | |||||
| Signature of Medical Assistant |
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| Signature of Medical Officer |
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| Doctor Name | |||||
| Qualification | |||||
| Registration No | |||||