/ MEDICAL REPORT

. ( To be filled in by the Examinee himself)

NAME : _______________________________________________________________________( FULL NAME IN BLOCK LETTERS)

ADDRESS : ____________________________________________________________________

1. ?Have you ever had any serious illnessor Surgical operations? _________________________________________

2. .. ?Have you or has any member of yourfamily ever been under treatment fortuberculosis? ________________________________________

3. ?Have you or has any member of yourfamily ever suffered from medical disease,fits or epilepsy or been treated in aninstitution for any kind of these diseases? _______________________________________

4. "" ?Have you or has any member of yourfamily ever been under treatment for trachoma? _______________________________________

"" - -State if Normal if not give particulars of any departure from Normal :

Husband or single man : Date of Birth :

_____________________________________( /Signature of the Examinee)

Wife or single woman : Date of Birth :

. ( )B. (To be filled in by the Examining Doctor)

Max. Min. Max. Min.

a) Heartb) Blood Pressurec) Lungsd) Nervous Systeme) Mental condition & Intelligencef) Digestive Organsg) - - Skelton Bones & Jointsh) Skini) Hearingj) Sight (i) Without Glass R L R L

(ii) ( )With Glass (if worn) R L R L Cause of defect of sight

k) Genito Urinary Organl) - Urine Albumen or Sugar Presentm) Teethn) Deformities

HEIGHT WEIGHT

:

REMARKS : In case where the Medical Examiner is unable to describe the examinee as being in perfect health and development,he should state the exact nature of the defect which he finds and whether it is of a permanent nature of temporarynature._____________________________________________________________________________________________________________________________________________________________________________________________________________________

"" Certify that I have this day examined the above named and that the results are as set forth and I certify that in my opinion, subject to anyspecial observations under Remarks the above named is in good health and of sound constitution and not suffering from any mental orbodily defect.

____________________( )

(Signature & Qualifications) Address : _____________________

__________________________________________

DATE :