Sonipat Narela Road, Near Jagdishpur Village Sonipat, Haryana-131 001, NCR of Delhi, India

HEALTH CHECKUP CARD

Name : ………………………………………………………………………….

Age / Sex : ………………………………………………………………………… Student Photograph

SpacFather’s Name:
Duly Attested by the
Physician
Mother’s Name: ……………………………………………………………………….

Any Chronic illness (Past medical history): …………………………………….

Any Neuro-psychiatric illness: ……………………………………………………………

Allergies: ……………………………………………………………………………………………..

General Physical Appearance and Examination

Built: …………………………………………………………………….

Pulse: …………………………………………………………………….

Blood Pressure: ……………………………………………………..

Height: …………………………………………………………………...

Weight: ……………………………………………………………………

Clinical Examination …………………………………………………

Chest & Respiratory System: ………………………………………….

Cardiovascular System: ………………………………………………….

Per Abdomen: ………………………………………………………………

Central Nervous System: ………………………………………………..

Sonipat Narela Road, Near Jagdishpur Village Sonipat, Haryana-131 001, NCR of Delhi, India

Investigations

Left and right with color blindness test

Blood group : ………………………………………

Hb : ………………………………………

TLC : ………………………………………..

DLC : ………………………………………..

ESR : ………………………………………….

RBS : …………………………………………….

URINE R/M : ……………………………………………….

I hereby certify that I have examined Mr. /Miss ………………………………………………,

and found him/her to be medically fit.

Date: Physician’s Sign & Stamp with Reg. No.

I am aware of the medical data in this card which is absolutely true to the best of my knowledge
and no facts have been hidden to the examining physician.

Date: Signature of Parent/Guardian

Verification sign & seal of University Health Centre

Note: Examination to be done only by M.D Physician for male candidates &
M.D/M.S Gynecologist for female candidates.