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Medical Certificate

This document contains a candidate's personal and medical history for admission to an engineering/science course. It includes sections for personal details like name, age, and identification marks. The medical examination report lists measurements of height, weight, and vision. It is to be filled out and signed by a registered medical practitioner, who will certify if the candidate is fit or unfit for admission based on their physical examination.

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Naveen Kharb
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720 views2 pages

Medical Certificate

This document contains a candidate's personal and medical history for admission to an engineering/science course. It includes sections for personal details like name, age, and identification marks. The medical examination report lists measurements of height, weight, and vision. It is to be filled out and signed by a registered medical practitioner, who will certify if the candidate is fit or unfit for admission based on their physical examination.

Uploaded by

Naveen Kharb
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Entry No.

GENERAL EXPECTATIONS

Candidate will have good general physique with

(a). Vision : should be normal, In case of defective vision it should be


corrected to 6/9 in both eyes or 6/6 in the better eye.

(b). Hearing : Should be normal. Defective hearing should be corrected.

(c). Heart and: Should not have any abnormality and no history of mental disease or
Lungs Epileptic fits.

PERSONAL HISTORY

1. Name. ________________________________________________________
2. Father/Guardians Name _________________________________________
3. Age __________ Year _________Months ________ Date of Birth ________
4. Sex________________
5. Identification Mark on the Body_____________________________________
(This can be a mole, scar or birthmark)
6. Major illness/operation: __________________________________________
(Specify nature of illness/operation)
6(a) Declaration by student: I am not suffering from any chronic illness like Epilepsy,
Bronchial Asthma etc.

Signature of the Candidate

CheckList 02-2016 10
MEDICAL EXAMINATION REPORT
(To be issued by a Registered Medical Practitioner)

MEDICAL CERTIFICATE

(Item 7-19 to be filled by Medical Officer conducting the Medical examination)

7. Height ____________cm. 8. Weight _____________ Kg.


9 Past History 10. Chest
(a) Mental Disease __________ (a) Inspiration ___________cm.
(b) Epileptic fit ____________ (b) Expiration ____________cm.

11. Vision with or without glass 12. Hearing_ __________________


(a) Right eye_______________ 13. Abdomen
(b) Left eye _______________ (a) Liver __________________
(c) Color Blindness________ (b) Spleen ________________

14. Respiratory system 15. Nervous system


16. Blood Group ____________
17. Heart
(a) Sounds____________ 18 (i) Hernia __________________
(b) Murmur ___________ (ii) Hydrocele _______________

19. Any other defects ________________________________________________


Certified that _____________________________________________son/daughter of
_____________________________________________________________________

a) fulfills the prescribed standard of physical fitness and is FIT for admission
to engineering/science course.

b) does not fulfill the prescribed standard of physical fitness and is unfit/
temporarily unfit for admission due to following defects:

_____________________________
Signature of the Medical Officer
Date _______________

Regn. No._________________

SEAL

CheckList 02-2016 11

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