NAME OF THE CLINIC: ________________________________________________

NAME OF THE DOCTOR: _______________________________________________

ADDRESS: _____________________________________________________________

CONTACT NO: ________________________________________________________

DATE: ________________________________________________________________

MEDICAL CHECK UP REPORT

Name of the person examined: __________________________________________

Age: _______________________________________________________________
Address: ____________________________________________________________
_____________________________________________________________
Identification Mark:___________________________________________________

(1) PHYSICAL EXAMINATION:

a. Any physical deformity__________________
b. Weight________ kgs.
c. Any recent change in weight______________
d. Height_________cms

(2) GENERAL EXAMINATION:

a. Eyes:
Visual Acuity
Acuity of vision Naked Eye With glasses
Distant Vision LE
RE
Near Vision LE
RE

Defect of color vision: _________________________________________

Night blindness: ______________________________________________

Any progressive diseases: ______________________________________

b. Ears
 Hearing: Left Ear____________________ Right Ear_________________

c. Mouth
Tongue_____________________________________________________
Tonsils______________________________________________________
Throat______________________________________________________
d. Glands and lymph nodes: _______________________________________

(3) VITAL DATA

a. Pulse______/ minutes
b. BP______________m.m. of Hg.
c. Respiratory rate_______/ minute

(4) SYSTEMATIC EXAMINATION

a. Respiratory system___________________________________________
b. Heart: any organic: ___________________________________________
c. Abdomen:
i. Liver_________________________________________________
ii. Spleen________________________________________________
iii. Tenderness____________________________________________
iv. Distension_____________________________________________

d. Genito Urinary System:

i. Hydrocele_____________________________________________
ii. Hernia________________________________________________
iii. Varicocele_____________________________________________
iv. S.T.D_________________________________________________

e. C.N.S.:
i. Any mental disability____________________________________

f. Locomotor System: ___________________________________________

(5) UNDERGOING ANY TREATMENT: ________________________________

(6) PAST HISTORY:

a. Any major illness:_____________________________________________
b. Any major surgery: ___________________________________________

(7) INVESTIGATION:
a. Routine

BLOOD URINE
Hb Alb
 Tc Sug

Dc Micro

E.S.R.

R.B.S.

(8) REMARKS & RECOMMENDATION:

________________________________________________________________

MEDICAL CERTIFICATE

I hereby certify that I have examined Shri/ Smt. _________________________________

and cannot discover that he/ she has any disease, constitutional weakness or bodily
infirmity except __________________________________________________________.

I do consider/ do not consider this a disqualification for employment and for working in
night shift.

Sign of Person examined Sign of Doctor

____________________ ________________