OHC Mob.
MO Mob:
Email:
MEDICAL DEPARTMENT
EYE CHECK-UP REPORT

Date:
Name:......................... Age:    diff($to)->y;?> Sex:
Father's Name:.................. Blood Group............
EmpID:.................. Designation:....................
Deptartment....... Division.......
Company/ Contractor Name:..................
Emai ID:    MOBILE NO:   
PERMANENT ADDRESS:    ,,,,,,

Visual Activity:

 Without Glass R.E.-  /6      &   /6 L.E.-  /6      &   /6
With Glass R.E.-  /6      &   /6 L.E.-  /6      &   /6
Color Vision:.............

Refractive Power
Left eye
Right eye
DSPH
DCYL
AXIS
V
DSPH
DCYL
AXIS
V
Distance
Near(reading)

C/o:
OE:

Prev.Diagnosis:
Treatment and Advice:
Next Check-up Date:
Remarks
This is to certify that Mr/ Ms ____________________________ has been examined and he / she is found to be medically for duty.
Signature: Date: Date:
Factory Medical Officer
Form No:TML/F/MED/01
Rev: 03