MEDICAL FITNESS FORM

(Must Submit Original Copy at the time of Admission)

Md Jubayer Ahmed
NAME : _________________________________________

AGE 18
: ___________ SEX: Male/Female

Personal History : Addiction to Tobacco / Cigarette/ Alcohol/ Other

Allergy/ To Drug/Food/Others
Family History : H/O of HTN / DM/ Br. Asthma/I.H.D
General Examination:-
Weight : 63kg
Height : 5.6"
Pulse : 90/min
B. P. : 120/80mmHg
EYE - Acuity of Vision
Colour Vision
EAR - 10/10
Blood Group- AB-

Dr. Khandokar Rafiqul Islam (Pollob)

B.M.D.C Regd No. 2109
(Verified by Medical Practitioner with Regd. No)

Please obtain the Medical certificate only from the following authorized Doctors:
1. Dr. S.K. Mitra Mobile no - 7250736916
Time : - 12 PM - 3 PM Place : St Xavier's College Clinic
2. Dr. N.K. Bhagat (Mobile No - 9431189435)
Time : 7 AM - 9 AM / 3.30 PM - 7PM
Place : Near Pantaloons, Lalpur