MEDICAL CENTRE
PRE - EMPLOYMENT MEDICAL EXAMINATION FORM FOR DRIVER
Sr No :
Date :
Name:
Age:
Sex:
Contact:
Emergency Contact No :
MEDICAL EXAMINATION PAST HISTORY
Personal History
Yes
No
Personal History
Yes
No
Smoking
Married
Alcohol
Unmarried
Tobacco Chewing
No Of Childrens
Drugs
M:
F:
Remarks :
MEDICAL HISTORY OF KNOWN ILLNESS AS SELF DECLARATION FOR PHYSICAL FITNESS
Disease
Yes
No
Disease
Yes
No
Diabetes
Heart Disease
Seizure Disorder / Epilepsy
High Blood Pressure
Head Injury Causing Symptom
Paralysis Of Any Type
Brain Tumor
Loss Of Vision
Shoulder Injury
Loss Of Hearing / Deafness
Muscle Disease
Tuberculosis
Asthma / Lung Disorder
Vertigo
Tinitus
H/o Unconsciousness
Mental Illness
Others
Past History Of Illness
Past History Of Illness
H/o Major Illness
H/o Any Deformity
H/o Any Accident
H/o Any Major Operation
Remarks :
GENERAL EXAMINATION:
Height:
Csm
weight_9:
Kg
SP02:
Disadvantages For Driving:
Posture / Deformity:
ENT:
Teeth:
Tongue:
Nails:
Skin:
Hearing Test:
Remarks:
MEDICAL HISTORY OF KNOWN ILLNESS AS SELF DECLARATION FOR PHYSICAL FITNESS
Eyes
Distant
Near
R
L
R
L
Uncorrected
Corrected
Colour Vision:
Field Of Vision:
Night Blindness:
Remarks :
Systemic Examination
cvs
Pulse:
B.P.:
mm of Hg
SIS2:
Murmur:
Remarks :
RESP. SYS.
:
Abdomen:
Genito-Urinary System :
Hernia:
Hydrocele:
Vericocele:
CNS:
Tandem Walking:
Finger Nose Test:
Extremities:
Rom At Limb Joints:
Muscle Power:
Higher Function:
Gait:
Spine:
BLOOD EXAMINATION
Blood Gr:
CREAT:
SGPT:
Hb% :
URINE R & M:
FBS/PPBS/R :
X-RAY CHEST:
Remarks :
Certificate
I Certify That Mr
____________________ is Examined
For Distant/near/colour Vision/field Of Vision & For Hearing Ability,
Hands /arms / Legs Deformity & Found.
Medicaly Fit In Regards Of Bodily Heath , Eye Sight, Mental And Health & Hearing
Medicaly Unfit For Following Reasons
Factory Medical Officer