Medical Check Up Form 2f584i

Health Check-up

First Name:

Middle Name:

Company’s Name: Employee Code :

PASTE YOUR RECENT PORT SIZE PHOTOGRAPH

Last Name:

Sr. No.: Department:

Designation:

Declaration I declare that the undersaid information is true and correct to the best of my knowledge. If any of this information is found to be false / incomplete / incorrect the company can cancel my appointment or terminate my service contract. No legal implications regarding the same will be borne by Bureau Veritas (India) Pvt Ltd or Bureau Veritas Certification (India) Pvt Ltd. Date: Thumb Impression / Signature of the candidate

Personal History 1. Smoking: ______________ Quantity: 2. Alcohol: _________ 3. Tobacco /Gutkha: Regular:

day for-Years: _________

Quantity: 4.Any Other:

6. Bladder; Normal / Regular:: Coffee:

day for- Years: 5. Bowel : Normal /

7. Diet: Veg. /Non Veg.

8. Tea /

9. Vasectomy:____________________________ 10. Any Allergies (Including Drugs):_________________________________________________

Health History Any Present Complains: _____________________________________________________ H/O Hypertension/Diabetes Mellitus/Heart Disease/Epilepsy : ______________________ Any other significant past illness: ______________________________________________ Any Accidents in past: _______________________________________________________ Any Surgical Intervention:____________________________________________________

Any Allergies (Including Drugs):________________________________________________ Any ongoing medications: Any Occupational Related Health Hazards (Previous/Present): ___________________________

General Examination Physical Parameters : Height :

Weight :

Physical Deformities : Conjunctiva : Pallor / Icterus : Nail : Pallor / Icterus / Clubbing : Edema : Pedal / Facial / Generalized : Nodes / Glands / Thyroid :

Ears / Nose / Throat (ENT) External Examination 1. Ear Examination : 2. Tonsils : 3. Sinuses : 4. Throat:

CVS (Cardiovascular System) 1. JVP.:

2. Heart Rate :

.

4. B.P. :

5. Heart beat-location :

3. Rhythm :

RS (Respiratory System) 1.Shape of Chest :

2. Chest Expansion Measurements:

3. RR :

4. Air Entry

5. Breath Sounds :

6. Added Sounds :

GIT (Gastro Intestinal System) 1. Bowel Sounds:

2. Tenderness :

3. Ascites :

4. Palpable Mass :

5. Organomegaly :

6. Any Other :

Se al

Certifying Physician Qualifications Reg. No.

PRE-EMPLOYMENT EVALUATION Date: ____________

R/No.: ______________

First Name: __________________ Middle Name _______________ Last Name______________________ Company’s Name: _______________________________________________________________________ Address: ______________________________________________________________________________ Tel No: _____________________________________ Email: ___________________________________

Declaration declare that the under said information is true and correct to the best of my knowledge. If any of this information is found to be false / incomplete / incorrect the company can cancel my appointment or terminate my service contract. No legal implications

PAST YOUR RECENT PORT SIZE PHOTOGRAPH

Regarding the same will be borne by Bureau Veritas (India) Pvt Ltd or Bureau Veritas Certification (India) Pvt Ltd.

SafetyofPledge Thumb Impression Signature the candidate Amelio Personnel From this day onwards, I solemnly affirm that I will rededicate myself to the cause of safety, health and protection of environment and will do my best to observe rules, regulations and procedure and develop attitudes and habits conducive for achieving these objectives. I fully realize that accidents and diseases are a drain on my Organization and the National economy and may lead to disablement, death, damage to health and property, social suffering and general degradation of environment. I will do everything possible for the prevention of accidents and occupational diseases and protection of environment in the interest of self, my family, my organization, my workplace, my community and the nation at large.

_________________________ Left Hand Thumb Impression _____________ Place

_____________________ Candidate’s Signature ______________ Date

__________________________________ Certifying Occupational Health Physician

CERTIFICATE OF FITNESS

1. Name of the Company : __________________________________________________________ 2. Serial No.

: ____________________________________________________

3. Name

: ____________________________________________________

4. Sex

: ____________________________________________________

5. Residence

: ____________________________________________________

6. Date of Birth

: ____________________________________________________

7. Physical Fitness

: Height: ____________

Weight: _______________

Chest

: Normal: ____________

Expanded: ____________

Eyesight

: Left : _____________

Right: ________________

8. General Examination

:

BP.: __________ CVS: ___________ RS: ___________ CNS: ________________ 9. Others

: ____________________________________________________

10. Advice : _____________________________________________________________________ 11. Descriptive Marks : I hereby certify that I have personally examined Mr. __________________, who is desirous of being employed in factory and that his/her age as nearly as can be ascertained from my examination is _______________ years and that he/she is FIT for employment in factory as an adult child his/her descriptive marks are : ____________________ 12. Reason for 1. Refusal of certificate : ____________________________________________________ 2. Certificate being revoked : _________________________________________________

__________________________

Left Hand Thumb Impression of Candidate

_______________

_____________________

Date

Certifying Industrial Health Physician