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    Satyendra Dubey
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    This document is a certificate of medical examination for employment. It contains information about the employee such as name, identification marks, father's name, date of birth, and physical fitness as determined by a medical examiner. The examiner certifies that the employee was examined and found fit for the intended employment. The medical record section collects additional health information such as blood group, vision, hearing, respiratory and cardiovascular measurements, abdominal exam, neurological history, and skin condition. The examiner can recommend further tests and signs the document.

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    This document is a certificate of medical examination for employment. It contains information about the employee such as name, identification marks, father's name, date of birth, and physical fitness as determined by a medical examiner. The examiner certifies that the employee was examined and found fit for the intended employment. The medical record section collects additional health information such as blood group, vision, hearing, respiratory and cardiovascular measurements, abdominal exam, neurological history, and skin condition. The examiner can recommend further tests and signs the document.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    6 views1 page

    Medical Form

    Uploaded by

    Satyendra Dubey
    This document is a certificate of medical examination for employment. It contains information about the employee such as name, identification marks, father's name, date of birth, and physical fitness as determined by a medical examiner. The examiner certifies that the employee was examined and found fit for the intended employment. The medical record section collects additional health information such as blood group, vision, hearing, respiratory and cardiovascular measurements, abdominal exam, neurological history, and skin condition. The examiner can recommend further tests and signs the document.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 1

    FORM-XI

    [See rule-223©]
    Paste photo
    CERTIFICATE OF MEDICAL EXAMINATION

    1. Certificate Serial No ___________________________________________________________Date____________________


    2. Name ______________________________________________________________________________________
    3. Identification marks(1)___________________________________________________________________
    4. Father’s Name ____________________________________________________________________________
    5. Residence ______________________________________________________________________Son/Daughter Of____________________________
    6. Date of birth , If available _______________________________ And/or certificate age ___________________________
    7. Physical Fitness
    I hereby certify that I have personally examined(name) _____________________________________________________________
    Son/daughter/wife of _____________________________________________ residing at _________________________________________
    Who is desirous of being employed in building and construction work and that his/her age as nearly as can be
    Ascertained from my examination is__________________________ years and that he/she is fit for employment
    In_______________________________________ as an adult/adolescent.
    8. Reason for-
    1) Refusal of certificate : _____________________________________________________________________
    2) Certificate being revoked : ________________________________________________________________

    Medical Record

    1. Name of the Contractor :


    2. Name of the employee :
    3. Date of employment :
    4. General survey : A) Health: - B) Height: - C) Weight :-
    5. Blood group :
    6. Eye Vision :
    7. Hearing :
    8. Respiratory system and chest Measurements
    i) Inspiration ii) Expiration iii) Remarks, If any
    9. Cardio Vascular system
    i) Plus Rate ii) B.P iii) Remarks, If any
    10. Abdomen Tenderness
    11. Nervous System
    History of fits : Yes/No
    Epilepsy : Remarks :
    12. Skin condition : Normal/Abnormal
    13. Recommendation if any for any further investigation :

    Signature/Left Hand thumb Signature Of the Medical Examiner


    Impression of the employee

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