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    Medical Certificate

    Uploaded by

    sayanialpanadas

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Medical Certificate

    Uploaded by

    sayanialpanadas
    22 views3 pages

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    22 views3 pages

    Medical Certificate

    Uploaded by

    sayanialpanadas

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 3

    Medical Fitness Certificate

    Candidate’s
    photograph, attested
    by the Medical
    Practioner

    (A) Personal information:

    1. Candidate’s name (in BLOCK letters): _________________________________________________

    2. Father’s /Guardian’s name: ____________________________________________________________

    3. Date of birth: ___________________________

    4. Present address: _______________________________________________________________________

    ___________________________________________________________________________________________________

    ___________________________________________________________________________________________________

    5. Permanent address: ____________________________________________________________________

    ____________________________________________________________________________________________________

    ____________________________________________________________________________________________________

    (B) History of illness:

    1. Past and present illness:

    2. Family history:
    (C) Physical examination:

    1. Height:

    2. Physical built:

    3. Deformity:

    4. Posture and gait:

    5. Condition of skin and mucous membrane:

    6. Teeth and gum

    7. Hearing:

    8. Mental alertness:

    9. Blood pressure

    10. Pulse and respiration

    11. Urine test for Albumin and Sugar:

    12. Blood test for TC, DC, ESR and Hb%:

    13. Vision: Right eye: Left eye:

    14. Heart:

    15. Lung (X-ray chest):

    16. Abdomen (Liver and Spleen)

    17. Menstrual History (For female candidates):


    (D) “I hereby certify that I have examined Mr./Ms. _______________________________________, a candidate

    for JENPAS(UG) training course and I couldn’t discover that he/she has any disease

    (communicable or otherwise), constitutional weakness or bodily infirmity, except

    _____________________________________. I do not consider this a disqualification for the said

    training.

    According to the statement of Mr./ Ms. _____________________________________, he/ she is


    ______________________ year old and by appearance he/ she is about ________________________ year
    old”.

    In view of the above findings, the candidate is


    a) FIT OR

    b) Unfit on account of __________________________________________________________________________


    OR

    c) Temporarily unfit on account of ___________________________________________________

    _________________________________________________
    Full signature of the candidate with date

    _____________________________________________
    Place: Signature of the Medical Practitioner

    Date: Name:

    Degree:

    Registration No.

    Official seal:

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