Part 1 — To be filled in by Candidate before Medica! Fvaminatin~ Post considered for: Name (in Block Letters) KAPIL DEV SINGH see eye) ear Meerut Busslent Address. Shi pike i pect) PM 250617 ate of birth pote ~ 02-FAB \q%e 1.Are you currently being treated by a health professional for any illness or injury? 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 you have 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 11. Do you drink alcohol? Date Serato iidate Left Hof ‘ Be Boression oF ShsPart 2 - Clinical Ex: amination/Lab test Cardiovascular system Kane. smi I Height S67 om. Blood pressure - (repeat if necessary) 7 ‘ Systolic a] mmi Diastolic Be mmHg b. Pulse rate Regular = _| irregular cc. Heart sounds Normal wa Abnormal ay d. Peripheral pulses Normal — Abnormal ChestLungs Normal We Abnormal Abdomen (Liver) Normal Abnormal Neurological/Locomotor a. Cervical spine rotation Normal 7] Abnormal b. Backmovement Normal Abnormal c. Upper limbs Appearance Normal um ‘Abnormal Joint movements Normal we Abnormal 4. Lower limbs ‘Appearance Normal ws Abnormal Joint movements Normal wv Abnormal e. Refiexes Normal WA Abnormal i f. Romberg's sign Normal uw Abnormal A pass requires the ability 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) Normal Tt] atime: Vision Test (Doctor's judgement) < He Routine Urine Examination Routine Blood examination him Nu sucar fel. © HAEMOGRAM Blood Group yh factor:__ Hb _/4- ne heaps DLC-PLEMB Platelet ane (keg Serum cholesterol ‘S/Triglycerides: HOL 53 LOL GyPart 3- Certificate of Physical fitness ihereby certify that Mr/MS. has been examined by us, we cannot discover that he / she has got any disease, communicable or otherwise, constitutional or bodily deformity except =_ Candidate is hereby declared, mea eee fe FIT UNFIT TEMPORARILY UNFIT for the post of Working on Height 2) Electrical work ‘Ah Material lifting v4) Four wheeler Driving 0 \ Doctor's full name Seal & Signature Sf, MANEHYIR ae DBS Registration DUMB ah Rea heen scum hee Date of examination 1 oe ate