Pre-employment medical checkup format by aniltheblogger

VIEWS: 24,737 PAGES: 4

									Date of Joining (dd /mm/year)

PRE-EMPLOYMENT MEDICAL CHECK-UP FORM Department : Blood group

T.NO.

Information to be filled in by Candidate:

P.C. No.

Designation (Trade): Date: Name: --------------------------------------------------------------------------------------------(Surname) (First name) (Father’s/Husband’s name) Date of birth: Gender : Male/Female dd mm year Address:--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

PERSONAL HISTORY: (Please write Yes / No in the space provided) Smoking:------Alcohol: -------Tobacco:-------Married:--------Number of sons:-------Number of daughters:--------Family Planning (FP) Operation on self:-----FP operation on spouse:-----Using “Contact lenses”:------Undergone “Laser” surgery on eyes:-----PAST AND PRESENT ILLNESS: (Please write Yes / No in the space provided) Asthma:-------Polio:--------Ear disease:---------- Venereal disease:-------Heart disease:---- Surgery undergone:-----------------Kidney disease:----------Diabetes:-------Leprosy:--------- High Blood Pressure:--------- Epilepsy(Fits):----Psychiatric illness:--------Major injuries:---------TB:------Bleeding disorders:------Any other diseases:----------Blood transfusion taken:-------Hospitalisation:-----------FAMILY HISTORY: (Please write Yes / No in the space provided) Asthma:-------- Heart disease:---- High Blood Pressure:--------TB:------Diabetes:-------Cancer:---------Psychiatric illness:--------Any other diseases:----------PAST OCCUPATIONAL HISTORY: Organisation Designation Service Past occupational illnesses (Trade) (in years) 1. 2. Certified that, the particulars given by me in the foregoing above are true, complete and to the best of my knowledge and belief. If any of this information is found to be false / incomplete / incorrect, the Company can cancel my appointment letter or terminate my service contract. I have / have not undergone medical check-up in TATA MOTORS unit in the past.

Signature of the candidate

FIT

UNFIT

PROVISIONALLY FIT

Signature of examining Doctor with his name and qualifications. “MALE CANDIDATES”

PRE-EMPLOYMENT CHECK-UP

Height:--------------- cms Weight--------------- Kgs Urine: Albumen: Present / Absent Sugar: Present / Absent Haemoglobin---------gms%

VISION: (WITHOUT GLASSES) Rt 6/ N/ Lt 6/ N/

NERVOUS SYSTEM Psychological make-up: Acceptable / Not acceptable Higher Functions: Normal / Defective Motor System: Normal / Defective Sensory System: Normal / Defective Reflexes: Superficial: Planter: Deep: MUSCULO SKELETAL SYSTEM: Normal / Defective

Distant Near

(WITH GLASSES) Rt 6/ N/ Rt Lt 6/ N/ Lt

Distant Near Sign of Medical Asst. CLINICAL EXAMINATION: Nails: Pink / Pale / Clubbed Oral Hygiene: Good / Poor Speech: Normal / Stammer Lymph Nodes: Not enlarged / Enlarged

Power Of Glasses Or Lenses Colour Vision: (with Ishihara Chart) Normal / Defective Individual Colour Identification: Normal / Defective Squint: Present / Absent Nystagmus: Present / Absent

GENITO-URINARY SYSTEM: Hydrocoele / Hernia Varicocoele / Phimosis Cryptorchidism / Varicose Veins

ENT EXAMINATION: Conversational Hearing: Normal / Defective Auroscopy: Nose: Throat: Thyroid: Enlarged / NE

CARDIO-VASCULAR SYSTEM: Pulse: / min, Regular / irregular Peripheral Pulsations: Felt / Not Felt Blood Pressure: 1st reading: mm Hg 2nd reading: mm Hg Other signs:

SKIN: Identification Mark:---------------------------------------Normal Eczema / Extensive Acne Vulgaris / Hansen’s / Melanoma / Neurodermatitis / Neurofibromatosis / Oil Acne / Psoriasis / Tylosis/ Venereal Warts

RESPIRATORY SYSTEM:

ALIMENTARY SYSTEM: Liver: Not enlarged / Enlarged Spleen: Not enlarged / Enlarged Other Signs:

X-Ray Chest: Normal / Shows positive findings Candidate FIT / UNFIT

Sign of Medical Officer Refer our Pre-employment “Standards” if you have any abnormal findings

PRE-EMPLOYMENT CHECK-UP Height:--------------- cms VISION: Weight--------------- Kgs (WITHOUT GLASSES) Urine: Rt Lt Albumen: Present / Absent Distant 6/ 6/ Sugar: Present / Absent Near N/ N/ Haemoglobin---------- gms% (WITH GLASSES) Rt 6/ N/ Rt Power Of Glasses Or Lenses Colour Vision: (with Ishihara Chart) Normal / Defective Individual Colour Identification: Normal / Defective Squint: Present / Absent Nystagmus: Present / Absent Lt 6/ N/ Lt

“ FEMALE CANDIDATES” NERVOUS SYSTEM Psychological make-up: Acceptable / Not acceptable Higher Functions: Normal / Defective Motor System: Normal / Defective Sensory System: Normal / Defective Reflexes: Superficial: Planter: Deep: MUSCULO SKELETAL SYSTEM: Normal / Defective Menstrual History: Menarche:---------Menstrual Cycle (MC): Frequency-----Regular / Irregular Last Menstrual Period Date: / / 20 Obstetric History: Gravida : Para: USG Pelvis Findings: SKIN: Identification Mark:---------------------------------------Normal Eczema / Extensive Acne Vulgaris / Hansen’s / Melanoma / Neurodermatitis / Neurofibromatosis / Oil Acne / Psoriasis / Tylosis/ Venereal Warts X-Ray Chest: Normal / positive findings Candidate FIT / UNFIT Sign of Medical Officer

Sign of Medical Asst. CLINICAL EXAMINATION: Nails: Pink / Pale / Clubbed Oral Hygiene: Good / Poor Speech: Normal / Stammer Lymph Nodes: Not enlarged / Enlarged Breast Examination:

Distant Near

ENT EXAMINATION: Conversational Hearing: Normal / Defective Auroscopy: Nose: Throat: Thyroid: Enlarged / Not RESPIRATORY SYSTEM:

CARDIO-VASCULAR SYSTEM: Pulse: / min, Regular / irregular Peripheral Pulsations: Felt / Not Felt Blood Pressure: 1st reading: mm Hg 2nd reading: mm Hg Other signs: ALIMENTARY SYSTEM: Liver: Not enlarged / Enlarged Spleen: Not enlarged / Enlarged Other Signs:

Refer our Pre-employment “Standards” if you have any abnormal findings


								
To top