MEDICAL CENTRE
PRE - EMPLOYMENT MEDICAL EXAMINATION FORM FOR TEMPORARY CANDIDATES.
Sr No.
Date:
NAME:
Age:
Sex:
Present History of Illness:
Present History:
Smoking:
Marital Status:
Alcohol:
Tobacco Chewing:
Others
:
Remarks
:
Past History:
H/o. Major illness:
H/o. Any Accident:
H/o. Any Major Operation:
Remarks
Family History:
Has anyone in the family suffered / suffering from
Diseases
Yes
No
Diabetes
Hypertension
Bronchial Asthma
Heart Diseases
Tuberculosis
Remarks :
GENERAL EXAMINATION
1. Height :
cms
2. Weight :
Kg
3. Built :
4. E.N.T. :
5. Teeth :
6. Tongue :
7. Nails :
8. Conjunctiva :
9. Skin :
10. Lymph Nodes :
11. Thyroid Gland :
12. Deformities :
Eyes
Distant
Near
R
L
R
L
Uncorrected
Corrected
Genito Urinary System :
Hernia:
Hydrocele:
Vericocele:
SYSTEMIC EXAMINATION:
1. Cardio vascular system:
Pulse
/ min.
Blood pressure:
mm of Hg
Heart sounds:
Murmurs:
Respiratory System
Shape of Chest
Chest Movements
Trachea
Breath Sounds
Abnormal Sounds
Abdomen
Liver
Spleen
Ascites
Any Lumps
Central Nervous System
Higher Functions
Cranial Nerves
Sensory System
Motor Functions
Reflexes
Locomotor System
Posture
Gait
Spine
Remarks :
Remarks: Medically
FACTORY MEDICAL OFFICER