Appendix 'D'

(Ref to Para 5 (d) of Joining

Instructions for NCC OTA,
Kamptee)

PRIMARY MEDICAL EXAMINATION REPORT (FOR PRCN & REF COURSE TRAINEES)

(To be completed by Physician with PG Degree in Gen Medicine)

1. Service No :NCC-06110455…………… 2. Name :Dr. Y.N.RAJA………

3. Father’s Name Y.SUBBA RAMAIAH 4. Date of Birth ..25-08-1981….

5. Service (Pl Tick) : ARMY /Navy/Air Force 6. Permanent Address ………..

297, RAJA NIVAS, 11TH MAIN, 11TH CROSS, NARASIPURA LAYOUT, VIDYARANYAPURA, BANGALORE-560097

7. Identification Marks :-

(a) A MOLE ON THE RIGHT LEG…………………………………………

(b) A MOLE ON THE RIGHT KNEE..………………………………………

8. Personal Statement :-

(a) Family History.

Relation If Alive If Expired

Age (Yrs) Health Cause of Death Died
(Yrs)
Father 72 V. GOOD
Mother 71 V.GOOD
Brother/Sister 36 V.GOOD

Any Family Hypertensi Heart Diabetes Bleeding Mental Night

History of on Disease Disorder Disease Blindness
NO NO NO NO NO NO
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Appendix 'D' (contd)

(b) Personal History.

Have you suffered from any of the following illness/conditions?

Illness (Yes/No) Illness (Yes/
No)
Chronic Bronchitis/ Asthma NO Discharge from ears NO
Pleurisy/Tuberculosis NO Any other Ear Disease NO
Rheumatism/Frequent Sore NO Frequent Cough & NO
Throats cold/Sinusitis
Chronic Indigestion NO Nervous Breakdown/mental NO
illness
Kidney/Bladder trouble NO Fits/Fainting Attacks NO
STD NO Severe head Injury NO
Jaundice NO
Air, Sea, Car, Train Sickness NO
Trachoma NO
Night Blindness NO
Laser treatment/Surgery for NO
Eye
Any other Eye disease NO
Have you ever been rejected as medically unfit for any branch of the Armed NO
Forces?
Have you ever been discharged as medically unfit from any branch of the NO
Armed Forces?
Have you ever been admitted in hospital for any illness, operation or injury? NO
Any other information you can NO
give about your health?
I hereby declare that I have answered all questions about my family and personal
health and that the information given is true to the best of my knowledge.

(c) I further certify that I understand :-

(i) I will be medically examined as per the medical standards required for
Commission in NCC.

(ii) The Regiment Medical Officers and other specialists of Armed Forces are the
final authority on such matters for declaring me FIT/UNFIT.

Left Thumb Impression of Candidate Signature of the Candidate

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Appendix 'D' (contd)

9. Physical Development.

(a) Height without shoes ….172............. Cms

(b) Weight.

(i) Actual :……80………Kgs (ii) Acceptable ...................Kgs

(c) Any other relevant observation. ( N/A)

(d) Evidence of Skin disease if any. (N /A)

10. Mental Capacity And Emotional Stability.

(a) Speech : NAD

(b) Evidence suggesting :-

(i) Mental Backwardness X (ii) Emotional Instability. X

11. Locomotion System. NAD

(a) Upper Limb. (b) Lower Limb. (c) Neck. (d) Trunk.

12. Teeth. NAD

(a) No of dental points. (b) Condition of Gums.

(c) Evidence of malocclusion.

13. Eyes. NORMAL R L CP

(a) Distant vision

(i) Without Glasses

(ii) With Glasses

(b) Near Vision N N

(c) Any evidence of trachoma or its complications or any other disease :-

14. ENT. (a) Right Ear (b) Left Ear. (c) Any evidence of Otitis media.

(d) Nose. (e) Throat.

NAD
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Appendix 'D' (contd)

15. Chest Examination: Measurement.

(a) Full Expiration ………..94…cm

(b) Range of expansion ..103...cm

(c) Abnormalities if any : NIL

16. Cardio Vascular System.

(a) Pulse…72…./min

(b) BP….10 /70…..mm of Hg.

(c) Heart Sounds: NORMAL

(d) Murmur : NO

(e) Blood Examination

(i) Hb%......13.8 gm%...................

(i) Blood Sugar F…80………PP…90…

(ii) Blood Urea…………

(iii) Creatinine …………………….

(f) X -Ray Chest. NORMAL

(g) ECG. NORMAL

17. Abdomen. NAD

(a) Liver. (b) Spleen. (c) Hernia.

(d) Hydrocele.

18. Genito Urinary System. NAD

(a) Urine

(i) Albumen…NIL. ….(ii) Sugar..NIL……..(iii) Specific Gravity………

(b) Abnormalities/Evidence of STD………NO…………………………..

19. Slight Defects not Sufficient to Cause Rejection : NO

20. HIV Status: NO

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Appendix 'D' (contd)

21. Immunization Status

(a) Tetanus : YES

(b) Typhoid : YES

22. In your opinion is the candidate FIT to undergo Military Training…YES……(Yes/No).

( Dr. Y.N.Raja -DC Service No. NCC-06110455 is FIT to undergo Military Training)

Place:
(Signature of Medical Officer)
Dated:
Name

Degree

Registration Number

COUNTERSIGNED BY CO
(With stamp and round stamp of Unit)