Date: _________________________

To,
The Director
Goa Institute of Management
Ribandar, Goa 403 006
MEDICAL CERTIFICATE
1. Full Name of the student
GIM ID/XAT ID:
Age
Identifcation Marks
2. Height (cms) (without shoes) Weight (Kgs.)
Pulse Rate p.m. Blood pressure Systolic Diastolic
Blood group 1
st
Reading
2
nd
Reading
3. Is the general appearance healthy?
4. i) Has he/she been hospitalised at
any time?
ii) Was he/she involved in an
accident?
iii) Has he/she undergone any
Radiological, Cardiological, Pathological
or any other tests?
iv) Is he/she currently under any
treatment?
If the answer to any of the next 8 questions (5 to 12) is yes please give full details.
5. Is there any abnormality of the
cardiovascular system?
6. Is there any swelling of joints, enlargement
of thyroid, lymphatic glands or scars (of
earlier surgery)?
7. Is any abnormality found on examination of
Mouth, Ear, Nose, Throat or Eyes?
8. Vision Normal? Yes / No
Hearing Normal? Yes / No
9. Are there any symptoms or signs suggesting
abnormality or disease of the Respiratory
system?
10. Is there any evidence of enlargement of liver
or spleen?
11. Is Hernia present?
12. Is there any evidence of disease of Central
or Peripheral Nervous Systems?
13. Is there any evidence of operation?
a)Year of Operation
b)Its nature and cause
c)Its location, size, condition of scar
d)Degree of impairment, if any
e)Duration of unconsciousness in the
case of head injury
14. Is there any other adverse feature in health
or habit, past or present, which you
consider relevant?
If so give details.
I hereby certify that I have, this day, examined the above student personally, in private,
and recorded in my own hand (i) the true and correct fndings (ii) the answers to Question
No. 4, as ascertained from the person examined. To the best of my knowledge and belief,
the student does not sufer from any communicable disease.
Signature of Medical Examiner:
Medical Examiners Name and Address: Qualifcation _______________________
Code No. _______________________