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Normal Medical Form

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AHESANALI GULAMHAIDER MOMIN

This medical certificate documents a medical examination. It includes the patient's name, age, date of birth, height, weight, medical history including conditions like tuberculosis or asthma, blood type, visual and auditory acuity tests, chest x-ray results, liver and kidney function tests, cholesterol and other blood work, blood pressure, syphilis and HIV tests, duty classification, medical care classification, and the examining doctor's details. The certificate comprehensively documents the results of the physical examination and laboratory tests.

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Normal Medical Form

Uploaded by

AHESANALI GULAMHAIDER MOMIN
14 views1 page
This medical certificate documents a medical examination. It includes the patient's name, age, date of birth, height, weight, medical history including conditions like tuberculosis or asthma, blood type, visual and auditory acuity tests, chest x-ray results, liver and kidney function tests, cholesterol and other blood work, blood pressure, syphilis and HIV tests, duty classification, medical care classification, and the examining doctor's details. The certificate comprehensively documents the results of the physical examination and laboratory tests.

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This medical certificate documents a medical examination. It includes the patient's name, age, date of birth, height, weight, medical history including conditions like tuberculosis or asthma, blood type, visual and auditory acuity tests, chest x-ray results, liver and kidney function tests, cholesterol and other blood work, blood pressure, syphilis and HIV tests, duty classification, medical care classification, and the examining doctor's details. The certificate comprehensively documents the results of the physical examination and laboratory tests.

Copyright:

© All Rights Reserved
Download as PDF, TXT or read online from Scribd
Download as pdf or txt
14 views1 page

Normal Medical Form

Uploaded by

AHESANALI GULAMHAIDER MOMIN
This medical certificate documents a medical examination. It includes the patient's name, age, date of birth, height, weight, medical history including conditions like tuberculosis or asthma, blood type, visual and auditory acuity tests, chest x-ray results, liver and kidney function tests, cholesterol and other blood work, blood pressure, syphilis and HIV tests, duty classification, medical care classification, and the examining doctor's details. The certificate comprehensively documents the results of the physical examination and laboratory tests.

Copyright:

© All Rights Reserved
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Download as pdf or txt
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MEDICAL CERTIFICATE

Name :
Date of Examination

Age :
Male / Female

Date of Birth (DD/MM/YY)

# Circle if applicable * Height * Weight

Anammesis Tuberculosis Hepatitis Gastric & Duodenal ulcer

Trauma Nephritis Other

Asthma Neurosis cm kg

*Blood Type ( ) Type. Rh ( ) Normal Range Results of Examination

*Visual Right . ( . ) CBC Hemoglobin

Acuity Left . ( . ) Red Blood Cell

*Color Sense Normal . Abnormal White Blood Cell

Right 1000Hz 4000Hz Normal Platelet

*Auditory Abnormal Hematocrit

Acuity Left 1000Hz 4000Hz Normal Normal Range Results of Examination

Abnormal Liver GOT (IU/l)

Chest Function GPT (IU/l)

X-ray g- GTP (IU/l)

Examination Direct HB (S) Antigen ( ) Antibody ( )

Total Cholesterol

Serum (mg/dl)

Lipid Triglyceride

(mg/dl)

Kidney Creatinine (mg/dl)

Date: Uric acid (mg/dl)

Electrocar- Glucose Glucose (mg/dl)

diogram (Blood)

Blood / mm/Hg Urinalysis Prot. Gluc. Urob.

Pressure / mm/Hg

Serological Test for RPR( Rapid Plasma Reagin)

Syphilis HIV TEST YES . NO


Classification(Duty) Classification(Medical Care) Address and Name of Doctor in Charge

W1 Sick Leave M1 Medical Care

Decision W2 Limited Duty M2 Periodic Checkup

W3 Regulated Living M3 No Checkup

W4 Normal Life M4 Healthy

(*) Not Required at Home Leave

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