MEDICAL EXAMINATION REPORT

Name :………………………………………………………… Sex : Male / Female

Passport :……………………………………………………… Age : ……………
………………………………………………………..

VITAL DATA : Height :…………….. Inspiration :…………………

Weight :…………….. Expiration :…………………
General Condition :………………

HEAD & NECK : Eyesight : Right : ………… Left : ………… with / without glasses

Ears : Right : ………… Throat : …………

Left : ………… Nose : …………
Colour Blindness : …………

LUNGS : …………………..

CARDIOVASCULAR : B.P (mmHg) : ………… Heart : ………… Pulse (/min) : ………….

ABDOMEN : Liver : ………… Spleen : ………… Other Masses :………....

Kidney : ………… Hernial Orifices : …………

CENTRAL NERVOUS:
SYSTEM ……………………

LABORATARY Urine S.G : ………… Blood : ………… Nitrite : …………

INVESTIGATIONS: PH : ………… Protein: ………… Glucose : …………

CHEST X-RAY : …………………

OTHER EXAMINATIONS : ………………..

I certify that I have examined Mr/Mrs …………………………………………….

on ……………………… and find that he / she is fit / unfit for the employment / study.

Yours sincerely,

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