FORM 31 - A

HEALTH CARD
(PRE-EMPLOYMENT / PERIODICAL)
(Prescribed under Rule 62 - J, Sec - 41 C)
1 Name of the Factory :

2 Name of the Employee :

3 Employee distinguish Number :

4 Age of the Employee :

Identification :

Nature of Job :

5 Date of Employment :

6 Length of Service in year :

7 General Survey :

Health : Good/ Fair/ Poor

Height : Cms.

Weight : Kg.

8 Blood Group :

9 Eye : Vision : Normal /Abnormal

Use of Glass : Yes / No

10 Hearing : Normal /Abnormal

11 Reapiratory System & Chest Measurement :

Inspiration :

Expiration :

Respiration Rate / mnt. :

Remarks , if any :

12 Cardiovascular System :

Pulse Rate :

B.P : mm of Hg

Heart Sound :

Remarks, if any :

13 Abdomen Tenderness : Yes / No

 14 Nervous System :

15 History of Fits : Yes / No

Epilepssy : Yes / No

Remarks on Mental Health :

16 Locomotor System : Normal /Abnormal

Remarks on any skin diseases Noticed :

17 Hernias : Present / Absent

18 Hydrocele : Absent / Present

20 Summary of Findings :

Heart disease :

Hypertension :

Diabetes :

T.B. : Normal /Abnormal

Epilepsy :

Poisoning :

Others :

Occupational Disease, If any :

21 Recommendation, if any, for any further investigation :

Signature of the Employee Signature of the Medical Officer

Date : Regd No.:
Date :