MEDICAL DEPARTMENT |
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Name: | Age: diff($to)->y; ?> Sex: |
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Father’S Name: | Blood Group: | |
Appointed for the Post of: | ||
E-mail ID: | ||
Mobile No. | ||
Identification Mark. | ||
Permanent Address: ,,,,,, |
A) Personal Information |
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Marital Status: | No. Of Children: | ||||||
Whether Adopting Any Method of Family Planning: | |||||||
Addiction: | Habits: | ||||||
Drug allergy: | Take Any Medication: | ||||||
B) Past and Present Ailment |
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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: | |||||||
C) Family History |
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Asthma: | Diabetes Mellitus: | TB: | |||||
Hypertension: | Any Others Diseases: |
Trade during last employment (for a period of one year) | Organization | Period of service | Past occupational illness if any | |||||||
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 |
BP: mm hg | Pulse: /m |
Chest: | Chest Inspiration: cm | Chest Expiration: cm (NA Female Candidate) |
Skin: | Muscular Skeletal: |
Hemoglobin: | % gm/dl | Total Leucocyte Count: | cu. /mm |
Differential Leucocyte Count | |||
Neutrophils: | % | Lymphocytes: | % |
Monocytes: | % | Eosinophil: | % |
Basophils: | % | ESR: | mm/1st hr |
FBS: | mg/dl | RBS: | mg/dl |
Uric Acid: | mg/dl |
Blood Urea: | mg/dl |
Creatinine: | mg/dl |
Total Bilirubin: | mg/dl |
SGOT: | u/l |
SGPT: | u/l |
Total cholesterol: | mg/dl |
(LDL) cholesterol: | mg/dl |
Triglycerides: | mg/l |
Urine RE/ME: |
Comments: |
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6/ | N/ | 6/ | N/ | |
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Deformities: congenital/Acquired
Findings: |
Comments: |
Nose: | Throat: | Ear: |
Audiometry: L.E.: R.E.: |
S1 & S2: | any other sound: |
ECG Finding: |
Spirometry Findings: |
Liver: | Spleen: | Tenderness: |
Any Other Abnormality: |
Q) Chest X-Ray (PA view): |
Any Other Findings: |
Health advices: |
Health risks: |
Remarks: |
This is to certify that Mr. / Ms. has been examined and he / she is found to be medically for employment. |
Signature: | Date: | Date: | |||
Factory Medical Officer |
Form No:TML/F/MED/01 |
Rev: 03 |