PRE-EMPLOYMENT MEDICAL EXAMINATION REPORT

A. BASIC DATA:

1. Name 2. Selected for the position of a) Date of Birth b) Identification marks

3 Unit & Location 4 Date of Joining B. CLINICAL EXAMINATION

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1. a) Height b) Weight 2. Chest measurements a) Normal b) Expanded 3. Abdomen measurements 4. Blood Pressure 5. Skin 6. Ear, Nose & Throat 7. Vision 8. Respiratory system 9. Circulatory system 10. Nervous system 11. Gastro-intestinal system 12. Genito-urinary system 13. Serious illness or operation in the past 14. Colour Blindness

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C. REMARKS ON PATHOLOGICAL TESTS

1. Chest X-ray 2. ECG 3. Complete blood count 4. Urine routine 5. Serum colesterol & blood urea 6. Fasting and post prandial blood sugar 7. Blood group
D. FAMILY HISTORY

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1. Father 2. Mother 3. Siblings

E. CONCLUSION

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1. Any further investigation required 2. Any precautions suggested

F. CERTIFICATION:

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Certified that the above named recruit does not appear to be suffering from any disease communicable or otherwise, constitutional weakness or bodily infirmity except __________________________________. I do not consider this as disqualification for employment in the Company.

Date Place

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Signature of the Medical Adviser

Seal of the Medical Hospital