Medical Report Form for examination of candidates for Gazetted Services A. Candidate's statement and declaration The Candidate must make the statement required being prior to his/her Medical examination and must sign the Declaration appended thereto. His/her attention is specially directed the warning contained in Note below:- 1 State your name in full (In block letter) 2. State your age and birth place. a) Do you belong to Scheduled Tribes or to races such as Gurkha, Garwalis, Assamese, Nagaland, Tribals etc. Whose average height is distinctly lower Answer 'Yes'or 'No' and If the answer is 'Yes' state the name of the tribe/race. 3. (b) Have you ever had small pox intermittent or any other fever, enlargement or suppuration or glands, spitting or blood, asthma, heart diseases, Lung disease, fainting attacks, rheumatism, appendicitis ? OR (a) Any other disease or accident requiring confinement to bed and medical or surgical treatment? 4. When were you last vaccinated ? 5. Have you suffered from any form of nervousness due to over work of any other cause? 6. Furnish the following particulars concerning your family.- Father's age if Father's age No. of brothers No. of brothers living and state at death and living their ages dead, their ages of health. Cause of death and state of health. At and cause of death. Mother's age if Mother's age No. of sisters No. of sisters Living and state at death and living their ages dead, their ages Of health. Cause of health and state of at and cause of Health 7. Have you been examined by a Medical Board before ? 8. If answer to the above is Yes, please state that service/services you were Examined for? 9. who was the examining authority? 10 When and where was the medical board held? 11 Resume Medical Board's examination if communicate to you or if Known, All the above answers are to the best of my belief, true and correct. Candidate's signature______________________ Signed in my presence. Signature of Chairman of the Board NOTE:- The candidate will be held responsible for the accuracy of the above statement .By willfully suppressing any information he/she will incur the risk of losing the appointment and ,if appointed, of forfeiting all claims to Superannuation Allowance Or Gratuity B. Report of the Medical Board on (name of the candidate). Physical Examination 1. General development: Good__________________ Fair ________________ Poor_______________ Nutritions__________________ Thin ________________ Average_____________ Obes_______________Height_____________(Without Shoes) _________________Weight _______________ Best Weight ___________________ When ______________any recent change in weight ? Temperature __________________ Girth of Chest (1) (After full inspiration) _____________________________________ (2) (After full expiration) _____________________________________ 2. Skin: Any obvious disease _____________________________________ 3. Eyes (1) Any Disease _______________________________ (2) Night Blindness _______________________________ (3) Defect in Color Vision _______________________________ (4) Field of Vision _______________________________ (5) Visual Acuity _______________________________ (6) Funds Examination _______________________________ Acuity of vision Naked Eye With Glasses Strength Sph of Classes By Axis Distant Vision Right Eye Left Eye Near Vision Right Eye Left Eye 4. Ears: Inspection________________ Hearing : Right Ear __________________________ ____________________Left Ear____________________________ 5. Glands___________________Thyroid____________________________ 6. Condition of teeth ____________________________________________ 7. Respiratory System: does Physical examination reveal anything abnormal in the respiratory organs ? ___________________________________________ If yes, explain fully ___________________________________________ 8. Circulatory System:___________________________________________ (a) Heart: Any organic lesions ? ______________________________ Rate: Standing _______________________________________ After hopping 25 times. ________________________________ 3 minutes after hopping ________________________________ (b) Blood pressure: Systolic________________ , Diastolic _________________ 9. Abdomen : Girth _________________ Tenderness ______________________ Hernia _________________________ (a) Palpable : Liver ____________________ Spleen Kidneys_________________ Tumors __________________________ (b) Hemorrhoids_______________________ Fistula ________________________ 10. Nervous System: Indications of nervous or mental disabilities _________________________________________________ 11 Loco-Motor System: Any abnormality _________________________________ 12 Genito Urinary System : any evidence of Hydrocele varicocle etc. Urine Analysis : (a) Physical appearance____________ (b) Sp. Gr._____________ (c) Albumin ______________ (c) Sugar_______________________ (e) Casts ______________ (f) Cells _________________ 13. Report of Screening/X-Ray examination of Chest ____________________________________ 14. Is there anything in the health of the candidate likely to render him/her unfit for the efficient discharge of rusher unfit for the efficient discharge of his/her duties in the service of which he/she is a candidate? 15. (i) State the service for which the candidate has been examined :- (a) Indian Administrative Service and Indian Foreign Services____________________ (b) IPS & Delhi Himachal Pradesh Police Service______________________________ (c) Central services, Class I & II____________________________________________ (d) Indian Forest Service__________________________________________________ (ii) Has he/she been found qualified in all respects for the efficient and continuous discharge of his/her duties in (a) Indian Administrative Service and Indian Foreign Service____________________ (b) IPS & Delhi Himachal Pradesh Police Service _____________________________ (See especially height, Chest girth eye sight colour blindness and locomotive system). (c) Transportation Traffic and Commercial Departments of the Indian Railways _______________________________________________________________ (See especially height, Chest, eye sight, colour blindness). (d) Other Central Service Class I & II ___________________________________ (e) Indian Forest Service___________________________________ (iii) Is the candidate fit for FIELD SERVICE ___________________ Note The board should record their findings under one of the following three categories: (i) Fit (ii) Unfit on account of _________________________ (iii) Temporarily unfit on account of. ______________ Space of Photograph Place ______________________ Dated ______________________ Mark Identification Signature's of Candidate Chairperson_____________ Member________________ Member________________ PROVISIONAL Signature of Candidate __________________________________________________. Certified that __________________________________________________________________________ S/o ________________________________________________________________________ whose signatures are given above appeared before the Standing Medical Board on __________________________ and declared fit for the post of ______________________________________________ in the Department of _______________________________________________________________________________________ Place : Chandigarh Dated Principal Medical Officer General Hospital, Sector 16 Chandigarh PROVISIONAL Signature of Candidate __________________________________________________. Certified that __________________________________________________________________________ S/o ________________________________________________________________________ whose signatures are given above appeared before the Standing Medical Board on __________________________ and declared fit for the post of ______________________________________________ in the Department of _______________________________________________________________________________________ Place : Chandigarh Dated Principal Medical Officer General Hospital, Sector 16 Chandigarh
