MAIHAR IU	Department	OCCUPATIONAL HEALTH CENTRE
		Document No.	F-MED-09
		Revision	0
		Implementation Date
Initial Medical Examination Card (LongTerm)

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SR . NO.
NAME
FATHER'S NAME
AGE/SEX	diff($to)->y; if($gender=='M') echo " Male"; elseif ($gender=='F') echo " Female"; ?>
ADDRESS
GRADE/POST
MOBILE NO.
GATE PASS NO./P NO.		DATE :
TO BE FILLED IN BY THE CANDIDATE
9.HISTORY PAST AND PRESENT ILLNESS [ if YES write √ if NO write X ]
ASTHMA (दमा)		DIABETES (मधुमेह)
T.B (टी.बी.)		HIGH BLOOD PRESSURE (उच्च रक्तचाप)
EPILEPSY (मिरगी)		PSYCHIATRIC ILLNESS (मानसिक रोग)
HEART DISEASE (हृदय रोग)		TYPHOID
HERNIA/ HYDROCELE		MAJOR INJURY/FRACTURE/ OPERATION
JAUNDICE		PILES/ FISTULA
10. PAST OCCUPATIONAL HISTORY
NAME OF ORGANIZATION	TRADE/DESIGNATION	PERIOD OF SERVICE- IN YEARS	PAST OCCUPATIONAL ILLNESS
11.PERSONAL INFORMATION
I. DATE OF BIRTH
II. IDENTIFICATION MARK
III. DATE OF EXAMINATION
IV. MARRIED/UNMARRIED
V. NO. OF CHILDREN
VI. WHETHER ADOPTING ANY METHOD OF FAMILY PLANNING
VII. SMOKING / TOBACCO / ALCOHOL

12.DECLARARTION: CERTIFIED THAT THE PARTICULARS GIVEN BY ME IN THE FOREGOING ABOVE ARE TRUE, COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. IF ANY OF THIS INFORMATION IS FOUND TO BE FALSE/INCOMPLETE/ INCORRECT, ONLY I SHALL BE RESPONSIBLE FOR IT AND COMPANY HAVE FULL RIGHT TO CANCEL MY APPOINTMENT OR TERMINATE MY SERVICE CONTRACT. मैं अपने पूरे होशोहवाश में यह प्रमाणित करता हूँ कि मेरे द्वारा दी गयी उपरोक्त समस्त जानकारी पूर्णत सही है, अगर मेरे द्वारा दी गयी कोई जानकारी गलत पाई जाती है तो उसके लिए पूर्णत मैं जिम्मेदार हूं एवं कंपनी को यह अधिकार है कि वो मुझे नौकरी में न रखे अथवा मेरी सेवाओं को समाप्त कर दे SIGNATURE/LEFT THUMB IMPRESSION OF CANDIDATE DATE
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
CVS				MUSCULO SKELETAL
S1		S2		CNS
ANY OTHER SOUND		ECG (12 LEAD) FINDINGS		ENT
2D ECHO/TMT FINDINGS				Conversational Hearing
				AUROSCOPY
				EAC
				NOSE
				THROAT
14. ILO CLASSIFICATION OF CHEST RADIOGRAPH (Enclosed Chest Radiograph)
PROFUSION OF PNEUMOCONIOTIC OPACITIES		GRADES		TYPES
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RESULT OF SPIROMETRY (REPORT ENCLOSED)
PARAMETERS			PREDICTED VALUE	PERFORMED VALUE	% OF PREDICTED
FORCED VITAL CAPACITY (FVC)
FORCED EXPIRATORY VOLUME IN 1 SEC (FEV1)
FEV1/FVC
PEAK EXPIRATORY FLOW
AUDIOMETRY FINDINGS ( REPORT ENCLOSED)
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		HBSAG
HIV		LIPID PROFILE
URINE RE/ME
APPEARANCE		PUS CELLS		RBCS
EPITHELIAL CELLS		OTHER RELEVANT FINDINGS		ALBUMIN
SUGAR
STOOL RE/ME
OPINION OF THE MO
REMARKS BY MEDICAL ASSISTANT
REMARKS BY DOCTOR
SIGNATURE OF MEDICAL OFFICER (WITH STAMP)