MEDICAL DEPARTMENT |
|
|
Name: | Age: diff($to)->y; ?> Sex: |
photo
|
Father’S Name: | Blood Group: | |
EMP/CL ID: | ||
E-mail ID: | ||
Mobile No. | ||
Designation: | ||
Name of Employer/Contractor: | ||
Bussiness Unit: | Department: | |
Section: | Sub-Section: | |
Permanent Address: ,,,,,, |
A) Personal Information |
||
Marital Status: | No. Of Children: | |
Whether Adopting Any Method of Family Planning: | ||
Addiction: | Habits: | |
Drug allergy: | Take Any Medication: | |
B) Past and Present Ailment |
||
Asthma: | Diabetes Mellitus: | TB: |
Hypertension: | Jaundice: | Epilepsy: |
Psychiatric Illness: | Hernia/Hydrocele: | Heart Disease: |
Piles/Fistula: | Night Blindness: | Typhoid: |
Major Injury/Fracture/Operation: | Spondylosis: | Leprosy: |
Thyroid: | Vertigo: | STD: |
Any other disease: |
I hereby declared that the particulars given by me in the foregoing are true, complete and correct to the best of my knowledge and belief, and if any of these information are found to be false/ incomplete/ incorrect, the organization is free to take appropriate action. | ||
Date: | Signature/ LTI of person examined |
Height cms | Weight kgs | BMI ... | Built & Nutrition...... | ||
General Inspection: | A: | CY: | I: | Cl: | E: |
BP:.....mm hg | Pulse:......./m | ||||
Chest:...... | Chest Inspiration:......cm | Chest Expiration:......cm (NA Female Candidate) | |||
Skin: | Muscular Skeletal: | ||||
General Weakness: | Smell: | ||||
Deformities: congenital/ acquired: |
Hemoglobin: % gm/dl | |
Total Leucocyte Count: cu./mm | |
Differential Leucocyte Count | FBS: mg/dl |
Neutrophils: % | RBS: mg/dl |
Lymphocytes: % | PPBS: mg/dl |
Monocytes: % | HIV: |
Eosinophil: % | HCV: |
Basophils: % | HbsAg: |
ESR: % |
Uric Acid: | mg/dl |
Urea: | mg/dl |
Creatinine: | mg/dl |
Total Bilirubin: | mg/dl |
Conj.: | mg/dl |
Unconj.: | mg/dl |
SGOT: | u/l |
SGPT: | u/l |
Alkaline Phosphatase : | u/l |
Total Protein: | g/dl |
Albumin: | g/dl |
Globulin: | g/dl |
Total cholesterol: | mg/dl |
(LDL) cholesterol: | mg/dl |
(VLDL) cholesterol: | mg/dl |
(HDL) cholesterol: | mg/l |
Triglycerides: | mg/l |
Speech: | Higher Function: | Motor Function: |
Vertigo: | Reflexes (Superficial & Deep): | Straight Line Walking: |
Vibration Syndrome: |
Conversational Hearing: | EAC: |
Nose: | Throat: |
Audiometry: |
Teeth & Gum: |
S1 & S2: | any other sound: |
ECG Finding: |
Spirometry Findings: |
Liver: | Spleen: | Tenderness: |
Any Other Abnormality: |
Chest X-Ray (PA view): |
Any Other Findings: |
Health Index : |
Health advices: = $health_advices ?> |
Health risks: = $health_risks ?> |
Remarks: |
This is to certify that Mr. / Ms. has been examined and he / she is found to be medically for duty.
= getFieldFromTable('user_name', 'tbl_users', 'user_id', $row_patient_physical_parameters['sign_medical_officer']) ?> | |||
Signature: | Date: | Date: | |
Factory Medical Officer |
Form No:TML/F/MED/01 |
Rev: 03 |