PRE-EMPLOYMENT MEDICAL
EXAMINATION RECORD FOR PROBATIONERS

SR. NO.

DATE:

NAME:				AGE:	SEX:
PRESENT HISTORY OF ILLNESS
PERSONAL HABIT SMOKING: ALCOHOL: TOBACCO CHEWING: OTHER: DIET:	MARITAL STATUS:			NO. OF CHILDREN MALE: FEMALE:
				F.P. HISTORY:
HAVE YOU SUFFERED OR ARE YOU SUFFERING FROM ANY OF THE ILLNESSES GIVEN BELOW. GIVE DETAILS IF ANSWER IS YES.
DISEASE	YES	NO	DISEASE		YES	NO
BRONCHIL ASTHMA			JAUNDICE
RECURRENT EAR, NOSE, & THORAT PROBLEM			ARTHRITIS/JOINT PAIN
ANY ALLERGY/EOSINOPHILIA			TUBERCULOSIS
DIABETES			KIDNEY/URINARY TRACT DISEASES
HIGH BLOOD PRESSURE			ANY SKIN DISEASE
HEART DISEASE			LEPROSY
EPILEPSY			ANY MENTAL DISORDER
CHRONIC DYSENTERY			ANY VENEREAL DISEASE
AT PRESENT ARE YOU SUFFERING FROM ANY OF CONDITIONS GIVEN BELOW GIVE DETAILS IF ANSWER IS YES			IS THEREANY HISTORY OF FOLLOWING THINGS IF YES, GIVE DETAILS
IMPAIRMENT OF HEARING			ANY MAJOR OPERATION
ANY EYE DISORDER			ANY ACCIDENT
ANY OTHER DISORDER (SPECIFY)			ANY EXPOSURE TO CHEMICALS
COVID-19			VACCINATION
DATE			1st DOSE	2st DOSE

HAS ANY ONE IN YOUR FAMILY SUFFERED/SUFFERING FROM THE DISEASES GIVEN BELOW

GIVE DETAILS IF YES

DISEASE	YES	NO	DISEASE	YES	NO
DIABETES			HEART DISEASE
HYPERTENSION			TUBERCULOSIS
BRONCHIAL ASTHAMA

FOR FEMALE CANDIDATES ONLY

	YES	NO		YES	NO
EXCESSIVE OR IRREGULAR MENSTRUAL PERIODS			LUMP IN THE BREAST
ANY COMPLICATIONS DURING PREGNANCY			GYNAEC SURGERY
			WHETHER ON ORAL PILLS/cu-T

IF THE ANSWER IS "YES" TO ANY OF THE ABOVE QUESTIONS, PLEASE GIVE DETAILS REGARDING NATURE OF ILLNESS DURATION AND YEAR OF OCCURANCE

DECLARATION BY THE CANDIDATE
I DECLARE THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

I CERTIFY THAT I HAVE NOT RECEIVED A DISABILITY CERTIFICATE/ PENSION OR COMPENSATION ON ACCOUNT OF ANY DISEASE OR OTHER CONDITION.

Date:

SIGNATURE OF CANDIDATE

3. GENERAL EXAMINATION:

HEIGHT: cms	WEIGHT: kg	BUILT:
ENT:	TEETH:	TONGUE:	NAILS:		DEFORMITIES:
CONJUNCTIVA:	SKIN:	LYMPH NODES:	THYROID GLAND:		ANY OTHER ABNORMALITIES:
EYES EXTERNAL EXAMINATION: COLOUR VISION:		VISION	DISTANT		NEAR
			R	L	R	L
		UNCORRECTED
		CORRECTED
GENITO-URINARY SYSTEM		HERNIA: HYDROCELE:

DISEASE	RESULT	REMARKS
ABDOMEN
LIVER
SPLEEN
ASCITIS
ANY LUMPS
CENTRAL NERVOUS SYSTEM
HIGHER FUNCTIONS
CRANIAL NERVES
SENSORY SYSTEM
MOTOR FUNCTIONS
REFLEXES
LOCOMOTOR SYSTEM
POSTURE
GAIT
SPINE

CARDIO VASCULAR SYSTEM:
PULSE: /min
BLOOD PRESSURE: mm Hg
HEART SOUNDS:
MURMURS:
PERIPHERAL PULSATIONS:

RESPIRATORY SYSTEM
SHAPE OF CHEST:
CHEST MOVEMENTS:
TRACHEA:
BREATH SOUNDS:
ABNORMAL SOUNDS:

INVESTIGATIONS

URINE EXAM	ALBUMIN:			SUGAR:			ACETONE:
	BILE SALTS:			BILE PIGMENT:			MICROSCOPY:
HAEMOGRAM	Hb: g/dL
	TLC: cumm		DLC	P:	L	E	M	B
				%	%	%	%	%
CRP: mg/dL
BLOOD GROUP
BIOCHEMICAL	BLOOD SUGAR
	F : mg/dL		PP/PG: mg/dL		RANDOM: mg/dL
	SGPT: U/L			SERUM CREATININE: mg/dL
	SERUM CHOLESTEROL: mg/dL			OTHERS:
STOOL EXAM	OVA:		CYST:			OTHERS:
X-RAY CHEST
ECG
PULMONARY FUNCTION TEST		MEASURED	% OF PREDICTED
	FVC
	FEV1
	FEV1/FVC
	MMF (FEF 25% -75%)
	PEFR
AUDIOMETRY TEST	RESULT	FREQUENCY	250	500	1K	2K	3K	4K
		LEFT EAR
		RIGHT EAR
REMARKS	Medically

Factory Medical Officer