Annexure li tr The candidate must make the statement required below prior to his medical examination and must sign the declaration appended thereto. His attention is specially directed to the waming contained in the note below: 1. State your name in full 2, State your age and birth place. 3. (@}_—-have you ever had small pox intermittent or anyother fever, enlargement of suppuration of glands, spitting of blood, asthama, inflammation of lungs, heart disease, fainting attacks, rheumatism, ar appendicitis. (b) any other disease or accident requiring ‘confinement to bed, and medical or surgical treatment. ‘OR (ce) have you ever been rejected by a medical Board or a duly constituted Medical Authority? When were you last vaccinated? Have you or any of your nearer relations been affected with consumption, scrofula, asthama. fits, epilepsy, or insanity? 6 Have you suffered from any form of nervousness due to overwork of afty other cause? 7. Furnish the following particulars conceming your on family: Ca oer [Fathers age if| Fathers age at] Number of | Number of living and state of | death and ‘cause | brothers living, | brothers dea. health of death their age and state | their age and ‘of health cause of death [ Vv T VI Mil vii | Mothers “age if| Mothers age at) Number of sisters | Number of sisters living and state of | death and cause of | living, their age |dead, their age health death and state of health | and cause of death | declare all the above answers ta be, to the best of my belief, true and correct and accept the findings of the Board as final. Candidate's SignatureMEDICAL EXAMINER'S REPROT: Question 1. Has the declaration af the preceding page been signed by the candidate? 2. Are there any evidences of malformation congenital or acquired ? 2. Is he free from sears and has he the full use of all limbs? | 4. Are there any indications of a decided cashetic or diathetic state of constitutior |. Are there any signs of disease ‘of the nervous system ? 6. Is the hearing good? Is there any sign of any ear disease? 7. Has the candidate been vaccinated within the last 12 months ? ‘8. What is the candidate's vision? R.E.V. with glass. Reads, L.E.V, with glasses. Spectacles if any LE. @. Is the candidate free from stamer or other serious defect in speech 2 10. Are there any signs of disease ‘of the bones, joints or parts connected therewith? 11. Is there any serious infection ‘of the skin? 12. (a) Is the heart and arteries healthy 2 (b} Blood pressure- | Systolic/Diastolic? 13, Has the candidate hhaemorrhoide, vericoele or other affection of veins? 14. Is there any sign of disease of the digestive organs? 15. Are there any signs of disease of the respiratory organs? 16. Is the candidate free from rapture’ _ 17. Is there any indication of disease of the genital organs? 18. (A) Is the urine free from: Answers Remarks| (1) Albumen (2) Sugar normal? 19, Is there anything in the health of the candidate likely to render him/her unfit for the efficient discharge of his/her duties in the service for which he is a | candidate? 20. Do you consider the candidate in all respects qualified for the efficient and continuous discharge of his/her duties in the service for which he/she is a candidate? k (B) Is the urine otherwise () Height without shass, (Girth of Chest (full inspiration). re | President. Member. Member. Note 1- The candidate will be held responsible for the accuracy of the above statement. By willfully suppressing any information, he will incur the risk of losing the appointment and, if appointed of forfeiting all claims to superannuation allowance or gratuity, Note 2- A candidate for direct recruitment should attach with the prescribed application a treasury receipt for an amount of Rs.100 on account of Medical Examination fee which shall not be refundable in the event of the candidates failing to be selected by the Medical Board.pee te: ay ‘Annexure Iv ‘The candidate must take the statement required below prior to his Medical Examination and must sign the Declaration appended thereto. Histher attention is specially directed to the warning contained in the Note Below - A 2 3 State your name in full {in block letters} State your age and bith place - - (a) have you ever had small-pox, intermittent or any other fever, enlargement or suppuration of glands, spiting of blood, asthma heart disease, lung disease, fainting attacks, rheumatism, appendicitis? (B) any other disease or accident Fequiring confinement to bed and . medical or surgical treatment ? onsen. When were you last vaccinated? Have you of any of your rear relations been affected with consumption, serofula, gout, asthma, fits, epilepsy, or insanity ? Have you suffered from any form of nervousness due to over-work or any ather cause ? Furnish the following particulars ‘concerning your family. a m1 T_ W | Fathers age ii and state of heaith | death and cause of | living, their age and | dead, their age and Fathers age at | Number of brothers | Number of brothers death slate of health cause of death v wi Wil vil Mothers age I'iving | Mothers age al |Number of sisters | Number of sisters and state af heaith | death and cause of | living, their age and | dead, their age and death state of health cause of death 10 "1 12, Have you been examined by a Medical Board before? If answer to the above is yes, please siate what service/services you were examined for ? Who was the examining authority ? When and where was the Iedical Board held ? Result of the Medical Board's Examination ifeommunicated to you or if known ? | declare all the above answers to be, to the best of my bebef, tue and correct. Candidate's SIGMAIUPE esse susie Signed in my presence. ‘Signature of the Chairman of the BoardNote: The candidate wil be held responsible for the accuracy of the above statement. By wilfully suppressing any information, helshe will incur the risk of losing the appointment and, if appointed, of forfeiting all claims to Superannuation Allowance or Gratuity (b) Report of Medical Board on (name of candidate) physical examination, 1. General development- Good Fair, POOF Nutrition: Thin... Average. ---OB888., Height (Without shoes), Weight... Best Weight, ae Any recent change IM WOIQM ance sseenstene cnn snes seens ene @MPOTALUTE., Girth of Chest (1) (After full inspiration) (2) (After full expiration) 2 Skin: Any obvious disease 3 Eyes (AhAny disease m (2) Night blindness (3) Detect in colour vision (4) Field of vision (S)Visual acuity Fa Acuity of vision Naked-eye With glasses Strength of glass Sph. Cyl, Axx Distant Vision RE Near Vision. RE Hypermetropia (Manifest) RE/LE 4. Ears Inspection. Hearing Right Bar... Left Ear . Bo lands thyroid 6. Condition of teeth 7. Respiratory System:- Does physical examination reveal ‘anything abnormality in the respiratory organs ? If yes, expiain fully & Circulatory Systern- (9) Heart - Any organic lesions 7 Rate Standing... (After hopping 25 times. 2 minutes after MOPPING... Diastolic... (b} Blood Pressure: Systolic... 8 Abdomen: Girth Tenderness. Hernia. (@) Palpatle: Liver... Kidneys... oan SPIER. Tumaurs,Place: Dated 0. 1" 12, (b) Hemorrhoids, Fistula... Nervous system: Indication of nervous or mental disabilities Loco-Motor System: Any abnormality. - Genito Urinary System: Any evidence of Hyderacele, Variocele etc, Urine Analysis= 13 (a) Physical appearance. (b) Sp Gr (@) Albumen. (8) SUA occu FO) CBBEEB scene () Calls. Report of X-Ray Examination of Chest, 's there anything in the health of the candidate likely to render him/her unfit for the efficient t olscharge of hismher autes inthe service for which heishe is a.candidate. Note:- The Beard should record their findings under one of the following three categaries:- Fit Unfit on account of... Temporary unfit on account of.