(TO BE EXAMINED AND SIGNED BY FACTORY MEDICAL OFFICER)


PATIENT DETAILS
Date: PME No. DOJ:
DESIGNATION: DEPARTMENT: DIVISION:
TRADE EMPLOYEE ID
NAME OF CANDIDATE: DOB: AGE
FATHER’S/HUSBAND’S NAME: GENDER: BLOOD GROUP:

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Test Names Result Unit Ref Range
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Additional/Other Tests
Test Names Result Unit Ref Range
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FACTS AND FINDINGS


Doctor's Findings Doctor's Comments
Health Risks : Health Advices :
Chronic Illness : Habits :

Signature & Stamp


KMC Reg No:



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