Babu Ishwar Sharan District Hospital, Gonda

Employee Health Check Up Form

Name: Age/Sex: :

Designation: Department:

1. Do you have any health complaints?

2. Are you currently, or have you ever been taking any medicine, pills or drug, or have been
investigated or hospitalized?
3. Has there been any recent gain or loss in weight? If yes, how much?
________________________________________________________________________
4. Have you ever had in the past or currently consuming tobacco / alcohol?
5. Have you ever had any kind of accident requiring hospitalization / taken treatment of more
than 7 days? If yes then provide details.
________________________________________________________________________
6. Have you ever undergone any type of special investigation (e.g. CT Scan, MRI etc.)? If
yes, give the reason and outcome.
________________________________________________________________________
7. Have either of your natural parents or any siblings died or suffered / suffering from cancer,
heart disease, stroke, Hypertension, diabetes, kidney disease, If yes, please provide details.
________________________________________________________________________
8. Is there any other information, not mentioned above which you would like to share with
us?
________________________________________________________________________
9. Are you allergic to any food items or drugs.

10. Cardiovascular System :

Pain Palpitation
Swelling Feet Breathlessness on Exertion

11. Respiratory System including Naso Bronchial Complaints :

Sneezing Running Nose Cough
Sputum Nasal Block Wheezing

12. Dental :
 13. Gastro Intestinal System :

Appetite Abdominal Pain Piles

Flatulence and Dyspepsia Mouth Ulcers Bowel Habits

14. Genito Urinary :

Frequency Day Night

Urgency Hesitancy Dribbling Overflow
Burning Hydrocele

15. Central Nervous System :

Headache (Gait) Abnormal moments Aura
Giddiness / vertigo Sleep
Memory and Concentration
Abnormal Sensation
Neuritis
16. Eyes Vision

17. Ears Hearing

18. Spine and Joints

19. Skin

20. General Symptoms (Prolonged Fever etc.)

21. Present Medications

Part II (Systemic Examination) :

1. General Physical Examination

Height & Weight Height (cms) Weight (kgs)

Blood pressure 1. 2.
Pulse / Min 1. 2.

General appearance (e.g. flabby, thin, muscular, pale, flushed etc.)

Pallor, Icterus, Clubbing, Cynaosis etc.

2. CVS : 3. Chest Shape 4. Heart Sounds

5. Murmurs 6. Thrills

3. RS : Rate & Type Breath Sounds

Adventitious Sound
Appearance
4. Abdomen :
Liver Spleen Kidney Others
Tenderness Bowel Sounds Hernia Fluid

5. CNS : Cranial Nerves Motor System

Sensory System Reflexes

6. EYES (Ophthalmology)
7. Extremities & Spine
8. Any Other

Part III
Investigation Required:

Investigation Results:

Treatment Advised:

Part IV
Final Impression :
1. Fit
2. Unfit
3. Fit with special condition

Recommendations :

Signature
(Physician/Medical Officer)