Schedule LIII-Form No. 380(New) O. C. S. (COMMUTATION OF PENSION FORM 4 (See rules 6,18,22,23,24,25 & 27) Medical examination by the.................... (here enter the medical authority) P A R T I The applicant must complete this statement prior to his examination by the .... ............... (here enter the medical authority) and must sign the declaration appended thereto in the presence of that authority. 1. Name of the applicant (in Block Letters) 2. Date of Birth (By Christian era) 3. Place of Birth 4. Particulars regarding parents, brothers and sisters. Father's age if living and state of health Father's age at death and cause of death No. of brothers living, their ages and state off health No. of brothers dead, their ages at death and cause of death Mother's age, if living and state of health Mother's age at death and cause of death No. of sisters living their ages and state of health No. of sisters dead their ages at death and cause of death. 1 2 3 4 5 6 7 8 2 5. Have you ever been examined : (a) For Life Insurance or/and ................ (b) By any Government Medical Officer or State Medical Board If so, state details and with what results 6. Have you been granted or considered for grant of invalid pension ? If so, state the grounds thereof. 7. Have you ever been granted leave on medical certificate during the last five years ? If so, state periods of leave and nature of illness. 8. Have you ever : (a) Had small-pox, intermittent or any other fever, enlargement or suppuration of glands spitting of blood, asthma, inflammation of lungs, pleurisy, heart disease, fainting attacks, rheumatism appendicitis, epilepsy, insanity or other nervous disease, discharge from or other disease of the year, syphilis or gonorrhea; or (b) Had any other disease or injury which required confinement to bed, or medical or surgical treatment ; or (c) Undergone any surgical operation, or (a) Suffered from any illness, wound or injury sustained while on active service ; (b) Presence of albumen or sugar in urine ; 9. Present state of health (a) Have you a hernia ? (b) Have you varicocele, varicose veins or piles ? (c) Is your vision in each eye good (with or without glasses) ? (d) If your hearing in each ear good ? (e) Have you any congenital or acquired malformation, defect or deformity ? (f) Have you lost or gained weight markedly during the last three years ? (g) Have you been under treatment of any doctor within the last three months and nature of illness for which such treatment was taken. 3 DECLARATION BY APPLICANT (To be signed in the presence of the Medical Authority) I declare all the above answers to be to the best of my belief, true and correct. I am fully aware that by willfully making a false statement or concealing a relevant fact. I shall incur the risk of losing the commutation. I have applied for and of having my pension withheld or withdrawn under rule 7 of the Orissa Civil Services (Pension) Rules, 1992. Applicant's signature or thumb impression in case of illiterate applicant Singed in the presence of (Signature and designation of Medical Authority) 4 PART II (To be filled in by the examining medical authority) 1. Height 2. Weight 3. Describe any scars or identifying marks of the applicant 4. Pulse rate (a) Sitting (b) Standing What is the character of pulse ? 5. Blood pressure (a) Systolic (b) Diastolic 6. Is there any evidence of disease of the main organs (a) Heart (b) Lungs (c) Liver (d) Spleen (e) Kidney 7. Investigations : (i) Urine (State specific gravity) (ii) Blood (iii) X-Ray Chest (iv) E.C.G. 8. Has the applicant a hernia ? (If so, state the kind and if reducible) 9. Any additional finding PART III (To be filled in by the examining medical authority) I/We have carefully examined Shri/Smt./Kumari.............and am/are of opinion that - He/She is/is not in good bodily health and has/has not the prospect of an average duration of life. Station ........ Signature and designation of Examining Medical Authority Dated .........
