You are on page 1of 3

ANNEXURE-I

MEDICAL CHECK UP REPORT

Reference SOP NO. HR/SOP - 002

Name of Employee : Employee Code No :

Designation : Date of Joining :

Department : Date of Birth :

A. GENERAL TEST:

S.No. Medical test Results for the Year :


Previous year Current Year
1 Age & Sex
2 Height
3 Weight
4 Chest Full Inspiration
Full Expiration
7 Nasal Passage
8 Throat
10 Circulatory system
11 Pulse Rate
12 Blood Pressure Systolic
Diastolic

S.No. Medical test Results for the Year :


Previous year Current Year
13 Abdomen
14 Nervous system
15 Sight Left Near
Distant
Right Near
Distant
16 Colour Vision
17 Hearing

Format No.: HR002-F01.01,Effective date: 14/01/15 1 of 3


ANNEXURE-I
MEDICAL CHECK UP REPORT

S.No. Medical test Results for the Year :


19 Tuber culosis
20 Contagious Disease

B. CLINICAL BIOCHEMISTRY

S.No. Results for the :


Medical test Normal Range
Previous year Current Year
1 Blood Sugar - 80 -160Mg/dl
Random

C. CYTOLOGICAL EXAMINATION OF BLOOD:

Results for the Year :


S.No. Medical test Normal Range
Previous year Current Year
Erythrocytes Male : 4.5 - 5.5 mill. Cu
1
(Red Bold Cell) mms,
2 Hemoglobin Male :13 to 18 g %
Leucocytes
3 4000 to 11000 cu. mms
(White Blood Cells)

D. DIFFERENTIAL COUNT : COUNTED 100 CELLS :

Results for the Year :


S.No. Medical test Normal Range
Previous year Current Year

1 Neutrophils 40 – 70 %
2 Eosinophils 02 – 06 %
3 Basophils 00 – 01 %
4 Lymphocytes 20 – 40 %
5 Monocytes 02 – 08 %
6 ESR (1 st Hour) 5-10 mm / hour
7 Platelet 1.4- 4.5 lacs /cumm

Format No.: HR002-F01.01,Effective date: 14/01/15 2 of 3


ANNEXURE-I
MEDICAL CHECK UP REPORT

E. ROUTINE EXAMINATION OF URINE :

S.No. Medical test Results for the Year :


Previous year Current Year

GENERAL CHARACTERS:
1 Quantity
2 Appearance
3 Specific Gravity
4 Reaction
CHEMICAL EXAMINATION:
1 Albumin
2 Suger
3 Bile Salts
4 Bile Pigments
MICROSCOPIC EXAMINATION :
1 Pus Cells
2 Epithelal Cells
3 RBC
4 Crystals
5 Cast
6 Others

HORMONE TEST

Results for the Year :


S . No. Medical test Normal Range
Previous year Current Year
1 Beta HCG Male : 1-2.5 mIU/ml
2 Testosterone Male : 241 – 827 ng/dL
3 Progesterone Male : 0.28 – 1.22 ng/mL
4 Follicle Stimulating Male : 1.4-181.1
Hormone mIU/mL
(FSH)
5 Leutinizing Hormone Male : 1.5-9.3 mIU/mL
(LH)
Note: Please Attached the Complete Medical Report.

Format No.: HR002-F01.01,Effective date: 14/01/15 3 of 3