CONFIDENTIAL

A.F.M.S.F. 18 (Ver 2002)

MEDICAL EXAMINATION REPORT
RELEASE/DISCHARGE
Authority for Board: MEG Record disch order Place Date of Date of Release
letter No 1362/CA/STATS-1/DO/May C/o 99 APO enrollment 31/05/2018
2018/17 dt 09 Mar 2017. 19/05/1999
Name Service No Rank Date of Birth
BALAPPA SP 15327848F L/NK 22/01/1980
Unit/Ship Service(Army/Navy/ Arm/Corps/Branch/ Total Service Married/Single
Air Force ) Army Trade: ENGRS/MEG 19 MARRIED
PERMANENT ADDRESS :- IDENTIFICATION MARKS
SUNAKUMPPI(VILL)
VANNUR (PO,) 1. BLACK MOLE OVER LEFT CHEEK
BAILHONGAL (TK)
BELAGAVI (DIST) 2. BLACK MOLE OVER MID Y 3 RD
KARNATAKA (STATE)
PIN-591 121
PART I
PERSONAL STATEMENT
1. Give details of service (P=Peace OR F=Field/Operational/Sen Service
Sl
From To Unit Location Peace/Field
No
(A) MAY 1999 OCT 2000 TB-III, MEG & CENTRE BENGALURU PEACE
(B) OCT 2000 OCT 2002 4 ENGR REGT LEH FIELD
(C) OCT 2002 OCT 2005 4 ENGR REGT NEW DELHI PEACE
(D) OCT 2005 NOV 2008 4 ENGR REGT SRINAGAR FILELD
(E) NOV 2008 JAN 2012 811 ENGR ONGC (TA) BARODA PEACE
(F) JAN 2012 JAN 2013 4 ENGR REGT SUJANPUR PEACE
(G) JAN 2013 APR 2014 UNMSN SOUTH SUDNAN FIELD
(H) APR 2014 SEP 2015 4 ENGR REGT SUJANPUR PEACE
(J) SEP 2015 OCT 2016 4 ENGR REGT AKHNOOR FIELD
(J) OCT 2016 TILL DATE 4 ENGR REGT KANCHARAPARA PEACE
2. Give particulars of any previous service in Army/Navy/Air Forces and state whether you were
invalided out of services.
3. Give particulars of any disease, wounds or injuries from which you are suffering
Illness, wound , injury First Started Where Approximate And period
Date Place treated dates treated

4. Did you suffer from any disability mentioned in question 3 or anything like it before joining
the Armed Forces? If so given details and date No
5. Do you claim any disability due to service? (Y/N) No
6. Any other information you wish to give about your health No
I certify that I have answered as fully as possible all the questions about my service and
personal history and that the information given is to the best of my knowledge.

Signature of witness…………….. Signature………..........................…

No 15327848F L/NK BALAPPA SP
Service No-16125689H Spr Avinash LW Date 2018
Note :- The question should be answered in the individual’s own words. This statement and
the data given above will be checked from official records as for as possible by the parent
Unit/Ship of the individual.
PART II
MEDICAL EXAMINATION
1.(a) Total Nos of Teeth Missing/Unsaveble Teeth
(b) Total Defective UR 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 UL
teeth
(c) Total Dental point LR 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 LL
(d) Condition of Gums Missing teeth to be indicated by Horizontal
(-)and Unsaveable teeth by a cross(x) through the appropriate
number

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2. Investigation
3. (a) Physical Capacity
(i) Height ………Cm (ii) Weight actual ………Kg (iii) Ideal Weight…………….Kg
(iv) Over weight………% (v) Waist …………………Cm (vi) Chest full Expiration…….Cm
(vii) Range of Expansion ……………………………...Cm
(b) Skin NAD/
(c) Cardio Vascular system
(i) Pulse………m (ii) BP………….mm/Hg (iii) Peripheral Pulsations NAD/
(iv) Heart Size NAD/ (v) Sound NAD/ (vi) Rhythm NAD/
(d) Respiratory System NAD/
(e) Gastro Intestinal System
(i) Liver Palpable (Y/N)……………….Cm (ii) Spleen Palpable (Y/N) ………… Cm
(f) Central Nervous System
(i) Higher Mental Functions NAD/ (ii) Speech NAD/……… (iii) Reflexes NAD/…....
(iv)Tremors Nil/Fine/Coarse…………… (v) Self Balancing Test Fairly Steady/Unsteady
4. (a) Loco motor System NAD/ (b) Spine NAD/
(c) Hernia NAD/ (d) Hydrocele NAD/
(e) Hemorrhoids NAD/ (f) Breast
5. (a) Distant Vision R L (b) Near Vision R L (c)CP

Without glasses Without Glass

With Glass With Glass

6. (a) Hearing R L Both (e) Audiometric Record
FW cms cms cms
CV cms cms cms
(b) Tympanic
Membrane Y/N Y/N
Intact
(c) Mobility (Vasalva)
(d) Nose, Throat & Sinuses NAD/
7. Gynecological Exam NAD/
8. CERTIFICATE FOR COMMUTATION OF PENSION I have carefully examined
No 15327848F L/NK BALAPPA SP of 4 ENGR REGT and I am of the opinion that the individual
is in good bodily health and has the prospect an average duration of life. Commutation of
pension in his / her case is therefore, recommended for acceptance.
Fit for release in SHAPE-I medical category
Place C/o 99 APO

Dated 2018 Signature of MO

Notes: 1. Delete what is not applicable. In case any abnormality is detected delete “NAD” &
enter finding
2. In case any disability is discovered, the individual is to be brought before a
recategorization medical board and AFMSF 16 is to be completed instead of his form.
PART III
REMARK OF OC UNIT/SHIP : Under Rule 13(3) Item 1(i)(a) of the table annexed to Army
Rule 1954.
I concur with the above /
Place: C/o 99 APO
Date : 2018 Signature of OC

PART V
PERUSING AUTHORITY
(Where applicable)

Place : C/o 99 APO Signature

Date : 2018 Rank & Designation

CONFIDENTIAL