MEDICAL DEPARTMENT

Date of Examination :
PEME CARD
PEME No.
Name:    Age:      diff($to)->y; ?>      Sex:  
photo
Father’S Name:    Blood Group:   
Appointed for the Post of:   
E-mail ID:   
Mobile No.   
Identification Mark.   
Permanent Address:    ,,,,,,
0) { $rowl = @mysqli_fetch_array($resultl); $param_present = (explode(', ', $rowl[0])); } $flag = 0; if (mysqli_num_rows($resultl) > 0) { foreach ($param_present as $x => $val) { if ($val == $illness_id) { echo '√'; $flag++; break; } } } else { echo ''; } if ($flag == 0) { echo 'X'; } } ?>

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:   

C) Family History
Asthma:    Diabetes Mellitus:    TB:   
Hypertension:    Any Others Diseases:   

D) Past Occupational History

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



E) CLINICAL EXAMINATION

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:   

F) BLOOD ROUTINE EXAMINATION

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

G) RENAL FUNCTION TEST

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

H) LIVER FUNCTION TEST

Total Bilirubin: mg/dl
SGOT: u/l
SGPT: u/l

I) LIPID PROFILE

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

J) EXAMINATION OF URINE

Urine RE/ME:
Comments:

K) EYE

Vision Without glasses/with glasses
Right eye
Left eye
Distant
Near
Distant
Near
6/ N/ 6/ N/
Colour perception
Remarks

Deformities: congenital/Acquired

L) CNS

Findings:
Comments:

M) ENT

Nose:       Throat:       Ear:      
Audiometry:      L.E.:        R.E.:

N) CVS

S1 & S2:    any other sound:   
ECG Finding:   

O) Respiratory System

Spirometry Findings:   

P) ABDOMEN

Liver:        Spleen:       Tenderness:      
Any Other Abnormality:       
Q) Chest X-Ray (PA view):    
Any Other Findings:    

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 employment.

Signature: Date: Date:
Factory Medical Officer      

Form No:TML/F/MED/01
Rev: 03