RUHUL AMIN

Dr. MD SHANI Dr.MD

MBBS, Reg. No. 86869ANSARI Reg. No. 77609
MBBS,
Physician&
Surgeon
General
General Physician &General Surgeon General
+919611970369
Q [email protected]
+917019606113
SNO-42022-1988 1Glnl2023
Name Buto tRize Age 8 Sex M Date

FIH-DMHTN/Asthma/lHD
FH-DMHTN/PUD/COPD/Asthma/lHD
R
Blood Group t
DH Systemic Examination
Smoker/Non Smoker/Betel Nut CVS Hb% 138
O/E RS FBS
1. BP |24Ii mm Hg
FNAD RBS 120MglDL
CNS
2. Pulse SbPM/min
3. RR |G CPM Imin
4. Temp g 8 F
5. Pallor e
6. lcterusO
7.Cynosis
8. Clubbing
9. Koilonychia
10. Lymphadenopathy
11 Edema
12. Nails
13. Dehydration
Adv' In T.[. o-S TM
14. MSK System
15. Others

Clinical Impression
clinicaly O2+jor IGlubo23Surgeon
Ruhul
MBDS,
Reg
Amin

No.-77609
,
&
Work MdPhysician
.
Dr.
Adv General
 FORM IX Workers
Regul(Under
ConstructionRules, 1998)
ation ofRuleEmpl223oyment
(C) ofthe Building and other
and Conditions of Services)
Central
EXAMINATION Passport
CERTIFICATE OF MEDICAL E Size
Pholo

1
2 Certificate Serial No. Certificate Serlal No.
Name
Buakie gei
() ldentification Mark
2.
at mak on lelI haud
(0) UANIAdhar No.
(un) Mobile No. 69942R19
3 A1o8319401
Name of Father/HusbandSurndaai
4 Sex
5 Date of Birth or Age Mal
Physical Fitness
1. Present Occupation
() Occupational History
2. Type of work being done
1. Smoking : YIN NO
2. Alcohol: Occasional/Regular NO
(i) Personal History 3 Other :(Tobacco, Pan, Bhang, Cigarette etc.) NO
4- Family details : Married/Unmaried
5. No. of Children
1. NO
7 (0) History of Past Fitness 2. NO
cms
1. Height
2. Weight T0 Kg
3. Blood Pressure 9u1 mm Hg
(ü) Personal History 4. Blood Group (
5. Pulse1bPM
6. Others
7. Any other specific disorder
person..Btathige
have personally examined the above named
Iherebycertify that I .soDaughter Wife.SanAN ....... ..residing at
KannivakuMani.)...AMi.adu.who is desirous of being employed in building construction
is.......... examination ..year
nearly as can be certained from my
work and that his/her age as ..as an adult/adolescent.
employernent in..
and thathelshe is fit for
8- Reason for
certificate.
1. Refusal of reworked.
being
2-Certified
Amin
hu l5urgeon
ctan
&.
SignaturelLelt Hand Thumb Md.
Worker Dr.
Impression of Building
Note Sig
Ce soalhpfcal Inspetor/CMO
1
2
 MEDICAL FITNESS CERTIFICATEDate.Ic.lLnlo.2.*
..........
For aPerson Work at Height Place Age.9.8..
Name of the Wale/Female

Mobile No.. Boto:Rie

Adr ess. . K Wor
anniyker
a. . KuMan. JaMLNodu. .Sex:
Location.NuPPL
1.Exami
To ngetation :Regarding Vertigo
ToWalkup.on. Straight
... D0000 To look up.
LE GT6
2. Ear/EyelCerebellum. line..... VA-REGG
Deafness.Sound..
Ringing
DiNystscharagmus.
ge.
Rombergs Sign..
3. H/O
Anti Consumption
of
Hyper Tensives...Drugs
Anti Histaminies.
Transquilizers.
4. Anemia.
Pallor.
5. Neck Movements.LNL
Neck Extension... WNL
Tenderness of neck muscles.
Mastoid Tenderness.
6. CVS
Asculation for Murmers
Post Test Observation
Sr. No. Particular Pre Test

1. Pulse/Min 1bPM 1bPM WNL

2 RR/Min CeM |6 CM UNL
BP/mm of Hg 19uls WNL
3.
observations on the points of cervicals
Based on above examination as well as clinical
H/O drug. consumption etc.
spondylitis. mastoid and ear problem, pallor, low BP and
icertify that
Mr..Brothise. is fit to work at height.

antihypertensive, anthisraminics
Note :-Advised NOT TO CONSUME particular drugs like Dr. Maahu Amin
l
for aperson working at height,
and tranguilisers

SignaturelHand Thumb
Impression of workmen
tiGER(MBBS)
 Name
FaAge:ther's Name SYMPTOMATIC COVID. 19 SCREENING FORM

Agency Name

Addres Sundaunuig Date

Mobile No

FEVER
COUGH
Knn iuakutmani
SYMPTOM YES
SYMPTOMS
NO SYMPTOM
NASAL DISCHARGE
YES
NO

BRELOSSSOREATOFTHROAT
HLESMELLS NES
BODY ACHE
ABDOMINAL PAIN
DIARRHOEA
CHEST PAIN
LOSS OF TASTE REDNESS IN EYES
HEADACHE
PAST HISTORY - COVID 19
HIO TRAVEL
H/O OF VACCINATION
IO OF CUARANTINE H/O OF CONTACT WITH COVID PT.

PO COVID-19 (e)
OTHERS:

ON EXAMINATION

BODY TEMP.
9C:8A
BP
9ul1c MMHg
SPO2
994@RA
PR
1beM.
RR
1Amin
&c
Surgeon
No.-77609

SOCIAL DISTANCING M
NOTE -WEAR MASK &MAINTAIN
 JAN SENA HOSPITAL
NEAR YAMUNA BRIDGE, BHILAWA HAMIRPUR(U.P)
Name Buaige Mob. No. 9936193469
DatRefe. by:1dliln Age28
Soxipmala

INVESTIGATION
NormalValue

Sub. In. Observed Value Unit

12-18gm%
HAEMOGLOBIN
BLOOD GROUP
13:9 gm %
O+ mm
Milion/Cu
RBC COUNT 4.5-6.6
4000-11000/cumm
TLC
40-72%
DLC
Neutrophils 20-44%
Lymphocytes 00-06%
Eosinophils 01-07%
Monocytes 00-01%
Basophils
37-47%
HCT
80-93%
MCV
28-32%
MCH
31-35%
MCHC
‘.5-4.0 lakh/ cu mm
PLATELET COUNT

Jansewafathology
Bhilawé, Hamirpur
PATHOLOGIEST

syrings for every patient

Note -We use sterilized disposable
purpose
This is not valid for medico legal