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    Anas Eltaf
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    13 views2 pages

    Physical Fitness

    Uploaded by

    Anas Eltaf

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    NESS CERTIFICAT PHYSICAL FIT! Vi (To be filled by a resiired ‘Medical practitioner in the applicants country of domicile) Name of Applicant Sex MIF A Marital Status wire Age Blood Group Se —~fAat—_. Nationality FE oa $< Address i ard, xe (ciy) —Kalut (Country) = AEH rel Telephone No. — 904? to BW HoNFQ Email Address Wbdulhadi hadi 22° Broil . Cone |. Medical History (Please give details of any past medical condition which may adversely impact the patient's health at the current time or in the near future). IA. History of Any Known Illness / Surgery:- Raised BP - Yes[_] No[Z> If, yes — on Regular treatment - Yes DM- Yes] No[{J ff, yes-on Regular treatment - Yes IHD - Yes[ No [ If, yes — on Regular treatment - Yes Stroke - Yes] NoFZT — if, yes~on Regular treatment - Yes N [ Kidney Disease: Chronic Renal Failure - Yes[_] Nof yes — on Regular treatment - Yes. (J Ne] Any history of Surgery / prolonged hospitalization (more than 2 weeks) Yes/No; if yes, details of illness / injury / Surgery with duration of ilness/ treatment Any history of loss of appetite - Yes No (2 Any history of loss of Weight - Yes] No Z& Any history of digestive diseases - Yes] No a Family History of : om] at Obesity Any known Allergy:- If 80, is the patient 0n 2°Y Medication / precautions? jutions? Physical Examination Medical condition of:- Height_ 4% % cm Weight__ 9's. Chest_AL AD CHormat) Head_N-A-D{ Noy Non, AE nial aoh_AL- ATS (Nan Eyes_Al A) (Nlomal’) Pharynx CALA (Aloumaltteart LALA 1D (Auiomal sy 4. Ears AA: Dl Alaina) Neck A, 4. 1 /a/ormal)Reflexes__al AI (Norma {) Remarks if any:- Sy Ml. Medical Examination:- Routine Blood, (including Fasting & P.P), Urine Test and Chest X-Ray and any other test as deemed fit by the Medical Practitioner (to rule out any chronic disease), IV. Summary | believe this applicant 1S / IS NOT physically able to carry on a full course of study, involving long hours of work, in a college or university in India. 2, In my opinion the applicant's health and physical condition in general are: L€xcellent Good Poor 3 | certify that the applicant is up-to-date on routine vaccinations including, among others, MMR, DPT, Varicella, Hepatitis A & B etc. 4, He /'She has no physical condition / aliment which would hinder him from pursuing a full course of study in India. y wale WV) 5. He/She present no evidence of any communicable disease or of any chronic fatigue. J ) (F) 6. He / She does not have any chronic medical condition which requires regular and sustained medical treatment. tynsel A) NOTE: If answers to 4, 5 and 6 above are positive, please give details in Remarks column below. remarks ll lab examination whicl, oe ane inelud tr en Signature peuleru —

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