Fitness No:

Appointment Date

Approval Date

Follow up to(if Applicable)

Treatment start Date

Treatment End Date

unfit From Date

unfit to Date

Date of Rejoining

you told the dispensary about the sickness

do you think you got sick because of work

what can be done to prevent it in future

Diagnosis

Body System

Doctor reference no.

Height (CM)

Weight (KG)

B.P

Pulse

Chest : Un-Expanded (CM)

Chest : Expanded (CM)

Blood Group

Nose

Throat

R.S

C.V.S

C.N.S

Treatment Agency

health status

Approval Status

Approval Remarks

Purpose of issue Certificate