BHARAT ELECTRONICS LIMITED(A GOVT. OF INDIA ENTERPRISES)

PLOT NO. L-1, TALOJA MIDC INDL.AREANAVI MUMBAI : 410 208

DIST.: RAIGAD

Pre-Employment Medical

Examination Report.

No. : ME/ Date :

Name :

For the post of :

1. Previous History a] Occupational (of importance) b] Medical

2. Family History(of importance)

3. Identification Marks 1]

2]

4. a] Apparent Age : a] Stated Age :

b] Any Deformity :

c] Conditions of the ThyroidLymph – nodes & Joints :

d] Evidence of any skin disease :

e] Varicose veins or filariasis :

f] Any other apparent abnormality:

5. Height : Exp. :

Weight : Chest :

Complexion : Insp. :

Colour of Eyes :

6. Alimentary System :

a] Conditions of the Teeth, Gums, :& Tongue-any oral senses.

Cont….2/-

: 2 :

b] Liver and spleen :

c] Any Evidence of Homorrhoies :Fistula or any other anorectal Pathology.

d] Any other abnormality :

7. Genito Urinary System

a] Urine-Albumin : MicroscopySugar Specific GravityDeposit Reaction

b] Any evidence of disease of Urinary System :

c] Any evidence of Ven. Disease :

d] Is Hernia present (give details)

e] Is Hydrocele present (give details) :

f] Any other abnormality :

8. Nervous System

1. a] Any evidence of Nervous disease :Chronic Headache, Paralysis,Epilepsy, Wasting Tremors etc.

b] Are the reflexes normal :

c] Any other abnormality :

9. Cardio-Vascular System

9.1 Heart : a] Size b] Positionc] Sounds

9.2 Pulse : a] Rate b] Rhythmc] Vol. d] Tension

9.3 Condition of Blood Vessel :

9.4 Blood Pressure : a] 1st Rg.

b] 2nd Rg.(Where necessary)

10. Respiratory System :

a] Any deformity or Abnormality of Chest.b] Condition of the Nose, Throat & Tonslis.c] Condition of the Lunge.d] X-Ray Report.e] Any Other abnormality.

Contd…3/-

: 3 :

11. Special Senses

a] Speech :

b] Ears : Hearing - Rt. Lt. Rt. Lt.

c] Vision : Any Eye Specialist’s report as per the proforma at Annexure-A is to be obtained and attached. All the columns specified therein are to be got filled in by the specialist and then duly certified and signed by him with his seal.

d] X-Ray : An X-Ray report from a Radiologist is to be obtained and attached as per the proforma at Annexure-B. All the columns specified therein are to be got filled in by the Radiologist and then duly certified and signed by him with his seal.

e] Any other abnormality :

11. For Female Candidates only

a] Any Menstrual disorder

b] Condition of the Breasts

c] Any evidence of Pregnancy

d] Any evidence of disease of the ovaries, utence or external genitals

e] Any other Gynecological abnormality

13. Special Investigations if any

14. Consulting Medical Officer’s remarks, if any.

Cont…4/-

: 4 :

15. Blood Group :

(Signature of the Candidate)

Signature of Medical ExaminerCompany’s Medical Officer (Seal & Signature)

Left Hand

Little Finger Ring Finger Middle Finger

Index Finger Thumb

Note: Please attach Eye Specialist’s report and X-Ray report as per the direction given in Col.No. 11 above.

Annexure – A

Vision Report : in respect of Shri / Smt.

I. External Eye Examination : Right Eye :

Left Eye :

Distance Vision : ------------------ ---------------Without Glass With Glass

Right Eye

Left Eye

Near Vision : ------------------ ----------------Without Glass With Glass

Right Eye

Left Eye

II. Colour Vision :

III. Funuds Examination :

IV. Conclusion :

Seal & Signature of the EyeSpecialist Certifying the report.

Annexure-B

Chest X-Ray Report (PA view) in respect of Shri / Smt.

I] Bilateral Lung Parenchyma spaces :

II] Position of Diaphragm :

III] Size and position of Heart & Aorta :

IV] Mediastinum position :

V] Pulmonary Vasculature :

VI] Hilar or Mediastinal Lymphadenopathy :

VII] Bony Thorax and Soft Tissues :

Seal & Signature of the Radiologist Certifying the report

Date :