MEDICAL DEPARTMENT

Date of Examination :
POHC CARD
POHC No.
Name:    Age:      diff($to)->y; ?>      Sex:  
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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:    ,,,,,,
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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

C) CLINICAL EXAMINATION

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:

D) BLOOD ROUTINE EXAMINATION

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: %

E) RENAL FUNCTION TEST

Uric Acid: mg/dl
Urea: mg/dl
Creatinine: mg/dl

F) LIVER FUNCTION TEST

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

G) LIPID PROFILE

Total cholesterol: mg/dl
(LDL) cholesterol: mg/dl
(VLDL) cholesterol: mg/dl
(HDL) cholesterol: mg/l
Triglycerides: mg/l

H) CNS

Speech:    Higher Function:    Motor Function:   
Vertigo:    Reflexes (Superficial & Deep):    Straight Line Walking:   
Vibration Syndrome:   

I) ENT

Conversational Hearing:    EAC:   
Nose:    Throat:   
Audiometry:   

J) Dental

Teeth & Gum:   

K) CVS

S1 & S2:    any other sound:   
ECG Finding:   

L) Respiratory System

Spirometry Findings:   

M) ABDOMEN

Liver:    Spleen:    Tenderness:   
Any Other Abnormality:   

Chest X-Ray (PA view):   

Any Other Findings:   
Health Index :   

Advice and Recommendations:

Health advices:     
Health risks:     
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