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Proforma For Medical Certificate

The document is a medical examination report template for engineering college admissions. It includes sections for personal history, medical certificate, and certification of fitness. The medical officer is to examine factors like height, weight, vision, hearing, respiratory and cardiac health, and check for any illnesses, and then certify if the candidate is fit for admission. The template guides collection of key health details to evaluate a candidate's physical fitness for the program.

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Gagan Prasad
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© © All Rights Reserved
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3K views2 pages

Proforma For Medical Certificate

The document is a medical examination report template for engineering college admissions. It includes sections for personal history, medical certificate, and certification of fitness. The medical officer is to examine factors like height, weight, vision, hearing, respiratory and cardiac health, and check for any illnesses, and then certify if the candidate is fit for admission. The template guides collection of key health details to evaluate a candidate's physical fitness for the program.

Uploaded by

Gagan Prasad
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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Dwarka Prasad Mishra


Hkkjrh; lwpuk izkS|kSfxdh] Indian Institute of Information Technology,
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¼lalnh; vf/kfu;e }kjk LFkkfir jk"Vªh; egRo dk laLFkku½ (An Institute of National Importance established by an Act of Parliament)

MEDICAL EXAMINATION REPORT


(To be issued by a Registered Medical Practitioner)

GENERAL EXPECTATIONS

Candidates will have good general physique. In particular,

a) Chest Measurement should not be less than 70 cm, with satisfactory limits of expansion
and contraction.

b) 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.

c) Hearing should be normal. Defective hearing should be corrected.

d) Heart and lungs should not have any abnormality and there should be no history of mental

PERSONAL HISTORY
1. Name ……………………………………………………………………………………..

2. Parent/Guardian’s Name ………………………………………………………………...

3. Age ……………………. Years ………………………… Months …………………….

4. Sex ……………………..

5. Identification Mark on the body, if any …………………………………………………


(this can be of illness/operation)

6. Major illness/ operation, if any…………………………………………………………..


(Specify nature of illness/ operation)

MEDICAL CERTIFICATE
(The following are to be filled by the medical officer conducting the medical examination)

1. Height ……………………………..cm 2. Weight ………………………………Kg

3. Past History 4. Chest

a) Mental Disease ………………….. a) Inspiration ……………………..cm

b) Epileptic fit ……………………... b) Expiration …………………….cm

5. Blood Group ……………………….. 6. Hearing ………………………………

7. Vision with or without glasses


a) Right Eye …………………………… b) Left eye………………………….

c) Color Blindness …………………….. d) Uniocular vision ………………...

8. Respiratory System …………………… 9. Nervous system ……………………..

10. Heart 11. Abdomen

a) Sounds …………………………….. a) Liver ……………………………….

b) Murmur …………………………… b) Spleen ……………………………..

12. a) Hernia ……………………………..

b) Hydrocele …………………………

13 Allergic from any medicine ………………………………………………………………

15. Any other disease ………………………………………………………………………...

16. If yes give details of medication …………………………………………………………


…………………………………………………………………………………………………
…………………………………………………………………………………………………
Certified that ……………………………………………………………………………

Son/Daughter of …………………………………………………………………………

a) fulfils the prescribed standard of physical fitness and is FIT for admission to Engineering.

b) does not fulfill the prescribe standard of physical fitness and is unfit/ temporarily unfit for
admission due to following disease.
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………

Signature of the Medical Officer Signature of the candidate

Date …………………………………………….

Full Name ………………………………………

Medical Registration No. ……………………….

Official Seal

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