HEIGHT PASS TEST REPORT

1. Name : Date :

2. Previous health history If any: examined :

3. Before Height pass Following are:

Pulse Rate : B.P:
4. After height pass following symptoms / Signs are examined:
Pulse Rate : B.P:
5) Mental Fit ness:
a) Un Controlled thoughts: Yes No
b) Fear of losing control: Yes No
C) Fear of Fainting : Yes No
6) Emotional Fitness :
a) Intense feeling to come down : Yes No
b) Warring about upcoming events: Yes No
7) Physical Fitness :
a) Palpitation : Yes No
b) Dizziness: Yes No
c) Chest pain: Yes No
d) shaking / shivering : Yes No
e) Feeling of Choking : Yes No
f) Sweating : Yes No
g) Nausea: Yes No
h) Numbness and Tugging : Yes No
i) Cold / hot flushes: Yes No
j) Flat Foot Yes No
Fit / Unfit to work at height Yes No

Remark If Any:

___________________________
Name and Signature of Doctor

Continue on Back Side of page

Test criteria for medical examination of operator, electrician, drivers, signalman, etc….

SR. NO Criteria YES NO

 1. Any past or present history of major medical or surgical illness.
2. Any case of epileptic disorder.
3. Suffering from any visual impairment or colour blindness.
4. Suffering from any auditory defect.

5. Suffering from any locomotors disability or spinal deformity.

6. Breathing peak & average flow rate is OK.
7. Upper Limbs – Adequate arm function and grip (both arms).
8. Lower Limbs – Adequate leg and foot protection.
9. General – Mental alertness and stability with good eye, hand and foot
co-ordination.
10 Any other point ---------------------------------------

This is to certify that I have examined Mr. ________________________________________ and found physically and
mentally fit to work as a ----------------------- at HRC.

____________________________________________
Signature of Doctor:
Name of Doctor:
Stamp with registration No: