1.

Personal details
M F
Occupation
3. When and the reason for your last visit
4. Have you in past five years consulting a doctor (
please also give name and full address)
Medical Examiners Report
ii. Medical/surgical history (Please give dates of any illness or injury and doctor consulted, in the space
provided)
Have you ever had ,
You are requested to put following questions to the person about to be examined and after recording the
replies , to obtain his or her signature thereto
Each individual question should be answered separately , and dashes or other marks should not be
used in places of an answer
3. National I.D. Number
1. Name
2. Age 2. Sex
1. Paralysis , epilepsy, fits or any psychological or nervous upset
2. Tuberculosis, pleurisy, asthma, bronchitis , persistent cough or
any other lung, ear, nose or throught complaints
3. Rheumatic fever or any disorder of the heart or circulatory
system
4.Persistence indigestion , gastric or duodenal ulcer, chronic or
recurrent diarrhea ,jaundice or lever disease
5.Diabetes, any kidney or bladder problem
6.Recurrent persistent fever or persistent night sweating
7.Any skin disorder
8.Any injury ,operation, physical defect or deformity
9. Hepatitis B or any sexual transmitted disease including genital
soars or discharges
13.Have you ever been refused as a blood donor
14.Have you suffered from tumors specially cancers
15.Have you taken any drugs other than for medical purposes or
had drug injected which were not prescribed by a doctor or
presently under medications or if so what
10.Any other disease , un explained infection or swollen glands
11.Any special investigations or tests ( including blood tests ) for
any disease or illness including aids or any suspicion on any
acquired immune deficiency syndrome or are you expected to
attend for such investigation or test
12 .Have you ever received any blood transfusion or blood
products
Section A : Medical and Surgical history
Consultations
Have you been advised to or have you consulted a specialist doctor or attended or hospital or clinic as an
inpatient or out patient within the last five years ? Minor injuries and uncomplicated pregnancy may be ignored)
if yes please give details
1. Name and the address of your regular doctor
2. How long have you been consulting the doctor
age
Father
Mother
Brother/sister
1
2
3
Signature of Examinee Witness ( Medical Examiner)
D. Social History
Do you consume any alcohol ( if yes please give
details including consumption per day /week)
Do you smoke? ( If yes please give the number
smokes per day/week )
Date reason
I here by declare that all the foregoing answers are true and that to the best of my knowledge and believe . I
have not concealed or withheld anything which may render the insurance on me/ my family more than usual
hazardous or with which the directors ought to be made acquainted.
F. Proposer Relationship
2. If you have attended the proposer personally, please provide particulars
health
Dated the day 20
a. Client Declaration
E. Family history
living Dead
age certified cause of death
kg
inch
inch
yesno
yesno
yesno
yesno
yesno
yesno
yesno
yesno
systolic diastolic repeat after 10 minutes if over 145/90
systolic diastolic
3. Heart sounds change of sounds YesNo cessation of sounds YesNo
4. pulse rate at rest after exercises
5. pulse character normal bounding small ( flat topped ) collapsing
6. position of the heart apex, Normal deviated
7. character of the apex size enlarged normal if enlargement slight moderate marked
1. Breathing sounds
Present of rhauls
present of ronchi
2. Bowel sounds
3. Heart sounds presence of murmurs
If murmurs presence please describe
If murmurs present please indicate the characteristics pre systolic
transmittent very loud localized loud soft/moderate very faint palpable thrill
absence with exercise change with exercises
presents not presents if presents state the possible cause
presents not presents if presents state the possible cause
presents not presents if presents state the possible cause
presents not presents if presents state the possible cause
presents not presents if presents state the possible cause
presents not presents if presents state the possible cause
1. any comments by the physician
2. Name of the examiner
2. Signature of the examiner
3. S.L.M.C. registration No,
4.Date
5. Rubber stamp of the examiner
if yes please specify
if yes please specify
if yes please specify
1.Chest ( chest formation ,chest movements,) if yes please specify
2. Abdomen (size of the lever, spleen
,abdominal tenderness )
Section B : Physical Examination
I. Proposers General description
inconstant constant
normal
Abnormal
normal
normal
II. Built up
IV. Physical examination
V. Auscultation findings
inch.
Inch.
III. Inspection ( if there is any abnormalities present please tick the appropriate box)
if yes please specify
4. Extremities (popliteal reflexes, status of
5.Skin ( skin lesions , discoloration )
6. Pelvis ( bladder, uterus, appendages,
7.Genitalia and breast ( testicles ect. )
3.Head and neck ( state of tong, vision,
hearing, thyroid, reflexes )
2. Blood pressure
1. Blood pressure
8.Spine (kidney, spinal code ect. )
if yes please specify
if yes please specify
if yes please specify
VII. Examinator's comments
1. Any deformity
2. Physique strong average weak
4. Chest at expiration
2. Weight
6.Weist
1. Height
3. Chest at full inspiration
5. Abdomen at umbilicus
ft.
inch.
2. other urine abnormalities
3. FBS - blood glucose
4. liver profile abnormalities
5. Chest x ray abnormalities
6. ECG Changes
presents same with exercise
VI. Laboratory findings
1. urine analysis- albumin