MEDICAL EXMINATION REPORT

Date:-________________________
Name Shri_______________________________________________Sex:_________________________
S/o, D/o, W/o: Shri__________________________________Date of Birth :_______________________
Post for which provisionally Selected : ____________________________________________________
Ref. Appointment Advise No. _______________________________ Dated _____________________

(Signature of Candidate) (Authorised Signatory)

PERSONAL & FAMILY HISTORY

Height_____________ Ear ___________ Hearing _____________________________
Weight ____________ Kg. Nose__________ Teeth ____________________________
Others _____________ Throat _____________ Skin _____________________________

Eye Sight : Without Glasses Without Glasses Near Vision

L/Eb R/Eb L/Eb R/Eb __________

Colour Blindness (if required)

Pulse ____________________________ Heart ____________________________
B.P. ____________________________ Lungs _____________________________
Abdomen ____________________________ CNS _____________________________
Liver ____________________________ Hornial Site _________________________
Spleen ___________________________ Hydrococle ___________________________
X-Ray Chest___________________________ Others ____________________________

BLOOD URNIE STOOL

HB% _________________ Anbumin___________________ Oa ______________________
TLC __________________ Sugar ___________________ Cyst _____________________
DLC _________________ Microscopic ___________________ Parssites __________________
ESR __________________ P____________________ Others __________________
Others___________________ L____________________ ___________________
Group ___________________ N____________________ ___________________
E____________________ ___________________

B____________________ ___________________

Identification Marks : ______________________________________________

Remarks : ______________________________________________
Observation : FIT/UNFIT for the Job __________________________

{ REGISTERED MED. PRACTITIONER}