Part 1 - To be filled in by Candidate before Medical Examination Post considered for: Name ( in Block Letters) LEVI70.AB Address : N'Sf Colomy House M2 - ol Dymapub SADRR Dateofbirth 18 /os 786 z 6 YES 1.Are you currently being treated by a health professional for any illness orinjury? 2. Do you use any drugs or medications prescribed by Doctor? 3. Doyou use any drugs or medications not prescribed by Doctor? 4. Do you have heart disease 5. Do you have high blood pressure 6. Do you have vertigo or fear of heights 7.Do youhave sleep disorder 8.Do you have Epilepsy 9. Have you ever had any serious injury, illness, operation, or been in hospital for any reason? 10. Have you ever been blackout/fainted SESE SE S/S} STSISTSTS] S 11. Doyou drinkalcohol? Date oa Left Hi pimpressionPart 2 - Clinicai Examination/Labtest Cardiovascular system BMI Blood pressure - (repeatif necessary) ‘Systolic Diastolic b. Pulse rate . Heart sounds d. Peripheral pulses > Chest/Lungs 4 Abdomen (Liver) 5 Neurological/Locomotor ‘a. Cervical spine rotation b. Back movement ©. Upper limbs ‘Appearance Joint movements 4. Lower limbs Appearance Joint movements @. Reflexes 1. Romberg's sign ‘Apass requires the abiity to maintain balance while standing with shoes off, feet together side by side, eyes closed and arms by sides, for 30 seconds Hearing (Doctor's judgement) Vision Test (Doctor's judgement) Routine Urine Examination Routine Biood examination Height 25 cm |Weight — 2oks. ‘Lo __| mmHg mmHg $O_|mmbg mmHg Regular 7é regular Normal [&, S¢-F [| Abnormal Normal ‘Abnormal Normal — [7 ‘Abnormal Normal [7 ‘Abnormal Normal [= ‘Abnormal Normal ie ‘Abnormal Normal is ‘Abnormal Normal ie ‘Abnormal Normal Vv ‘Abnormal Normal us ‘Abnormal Normai v ‘Abnormal Normal a ‘Abriormal Normal Vv ‘Abnormal AUN sucar Hep HAEMOGRAM 7 Blood Group: OF factor.» /4 — RBC. DLC-PLEMB Platelets Count_AL Serum cholesterol SMTrigycerides: HOL LoL.Part 3- Certificate of Physical fitness Loucl has been examined by us, we cannot discover that he /sbehas got any disease, vo hereby certify that Mr/Ms.. communicable or otherwise, constitutional or bodily deformity except_2& v Candidate is hereby declared, wv FIT UNFIT TEMPORARILY UNFIT for the post of 1) Working on Height 2) Electrical work 3) Material lifting 4) Four wheeler Driving Doctor's full name ty. ¢ 1S. Fungi Seal & Signature & Registration number ygtA A ie Date of examination A noone Se genior Specel "Hospital Diep i Nolen