MEDICAL FITNESS CERTIFICATE

Date:______________________

Name of Doctor : _________________________________________________________________________________________________________

Qualification: ____________________________________________________________________________________________________________

Registration No: _________________________________________________________________________________________________________

Employee’s Name/Candidate Name: ________________________________________________________________________________

NAME OF COMPANY: _AI ENGINEERING SERVICES LIMITED______________________________________________________

Blood Group: _____________________________________________________________________________________________________________

Designation:
______________________________________________________________________________________________________________

Department: _____________________________________________________________________________________________________________

Emp. No. /SAP No.: ________________________________Age:______________________________Sex _____________________________

Identification Mark: ____________________________________________________________________________________________________

Contact No:

PHYSIOLOGICAL PARAMETERS:

Ht.(Cms.) ______________________ Wt. (Kgs.) ________________________ Chest (Cms.) _____________________

COMPLAINTS: (Specify if any) (Yes/No)

Fever Appetite Loss Weight Loss Cough Chest Pain

Breathlessness Headache Palpitation Giddiness

Bleeding Orifice Any Rash Abd. Pain

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 Sign & Seal of Certifying Doctor

PERSONAL HISTORY (Addiction if any)

Chronic Frequent Occasional Smoker Nil

GENERAL OBSERVATION/SIGNIFICANT OBSERVATION, IF ANY ON THE FOLLOWING:

Respiratory System: comments from Doctor : _____________________________________________________________________

Cardiovascular System: comments from Doctor : __________________________________________________________________

Abdomen: comments from

Doctor :___________________________________________________________________________________

GENERAL EXAMINATION

Pulse (Min.): _____________________________ BP (mm/Hg): ___________________________________________

R.R (Min.): ______________________________ Temp.: ___________________________________________________

Remarks/Fitness: _________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

Signature & Seal of certifying Doctor Signature of Candidate