Form No.

: ADM/12 (R0)
Ref.: SOP/ADM/08
Medical Examination Record
Page 1 of 2

Employee’s Information entered by HR and Admin Department of MPPL

Name: Code No.: Age: Years
Department: Male Female Calendar Year: 2020
Type of Employee: Newly appointed / Temporary / Permanent / Casual / Contract / Other.
Medical Examination Report (Recorded by the Certified Physician)
Sr. Medical Examination Opinion of the Advice,
Observation
No. Performed Physician if any
1. Physical measurements Height: cm
Weight: Kg.
2. Eye Test:
Vision, colour blindness
and colour shade
recognition

3. Chest X-ray

4. Examination of blood TC:

DC:
ESR:
Blood Group:

5. Urine Test

6. Skin disease

7. HIV

8. Liver Function Test (LFT)

9. Pulmonary Function Test

(PFT)

Medical Certificate
The above person examined by the undersigned has been found medically
FIT / UNFIT.
Name of the Physician:
Registration No.:

Signature: Date:
Name of Hospital:
STAMP
Address: Contact No.:
 Form No.: ADM/12 (R0)
Ref.: SOP/ADM/08
Medical Examination Record
Page 2 of 2