Scribd
Upload
146 views2 pages

Medical Examination Form New

The document is an application for medical examination for fresh employment or re-employment at the W.U.S. Health Centre at the University of Delhi. It lists the required medical tests and examinations, including blood tests, imaging like chest X-ray, and physical examination of systems. It collects information from the applicant on their medical history, family history, and lifestyle factors like smoking and drinking. The medical examination report section documents the results of the physical examination and investigations, and the remarks of the examining medical officer.

Uploaded by

Shady Sharma
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
146 views2 pages

Medical Examination Form New

The document is an application for medical examination for fresh employment or re-employment at the W.U.S. Health Centre at the University of Delhi. It lists the required medical tests and examinations, including blood tests, imaging like chest X-ray, and physical examination of systems. It collects information from the applicant on their medical history, family history, and lifestyle factors like smoking and drinking. The medical examination report section documents the results of the physical examination and investigations, and the remarks of the examining medical officer.

Uploaded by

Shady Sharma
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
You are on page 1/ 2

W.U.S.

HEALTH CENTRE
UNIVERSITY OF DELHI
DELHI-110007
APPLICATION FOR MEDICAL EXAMINATION FOR FRESH/RE-EMPLOYEMENT/
COMMUTATION OF PENSION
The following document/test reports from University of Delhi empanelled Hospital(s) are being submitted for
medical examination:
1. Complete Blood Count 2. Blood Sugar- 3. LFT 4. KFT
Fasting/P.P./HbA1c
5. Lipid Profile 6. HBsAg 7. Anti - HCV 8. Urine – Routine
Examination/ME
9. Chest X-Ray PA View 10. Recent E.C.G. 11. Ultrasonography 12. Vision Report
Abdomen RE/LE
13. Fundus Examination
 Copy of appointment letter for employment/re-employment/Commutation of pension
 Two recent passport size photographs
Note: Clinico-pathological investigations are to be performed from any Govt./University of Delhi approved
Hospital(s) or Diagnostic Centre.
(To be filled by the Candidate)

1. Name (in block letters)...........................................................................................Gender: Male/Female

2. Date of Birth………………………….. College/Institution………………………………………...

3. Designation……………………………………… Department……………………………………..

4. Marital Status: Married/Single 5. Vegetarian/Non-Vegetarian

6. Do you smoke ? : Yes/No 7. Do you take Alcohol ? : Yes/No

8. When were you immunized against the following diseases :

COVID – 19 ……………………... Typhoid…………………. Hepatitis-B……………………..

9. Are you suffering from Hypertension, Diabetes Mellitus, Chronic Kidney Disease, Cancer (Kindly,

attach the relevant documents) ………………………………………………………………………….….

10. History of Surgery, Hospitalization (Kindly, attach the relevant documents) ………………………….…

11. Any other information about your health :…………………………………………………………….…...

12. Is your Father suffering from any disease ? :…………………………………………………………....…

13. Is your Mother suffering from any disease? :……………………………………..……………………….

14. Address : …………………………………………………………………………………………..………

15. Cell Phone No. :………………………………

SIGNATURE OF THE CANDIDATE


MEDICAL EXAMINATION REPORT

Name of the candidate……………………………………………………… Date of Examination………….


A. GENERAL PHYSICAL EXAMINATION:
1. Age :……………………. 2. Apparent: ………………………...

3. Built: Thin/Medium/Heavy 4. Nutrition : Adequate/Inadequate

5. Height:..……………cms 6. Weight :…………………kg

7. Chest Normal :……………..…cms 8. Chest Expanded :……………...…cms

9. Abdominal Girth :…………….cms 10. Pulse Rate/Volume/Rhythm :…BPM

11. Blood Pressure :………………mmHg 12. Skin/Hair/Nails :……………………

13. Lymph Nodes (Cervical/Axillary/Inguinal : significantly palpable/non palpable)

14. JVP : Raised/Not Raised 15. Pedal Oedema : Present/Not Present

B. SYSTEMIC EXAMINATION :

1. Eye (External) :……………………..... 2. Vision : RE/LE

3. Fundus Examination :……………….... 4. Ear/Nose/Throat/Teeth :

5. Cardiovascular System :………………. 6. Respiratory System:………………

7. Liver/Spleen/Kidneys : Palpable/Non-palpable 8. Bones/Joints/Muscles :……………

9. Hernia/Hydrocele/Varicose Veins : ….………………………………….………………………

10. Obstetric History/Gynaecological Exam.:……………………………………………………….

C. ANY LOCOMOTOR/HEARING IMPAIRMENT/VISUAL DISABILITY :

D. LABORATORY INVESTIGATIONS:

1. Haemoglobin ..……………..gm % 2. Blood Sugar Fasting ………PP……..mg% , HbA1c ……

3. LFT ……………… 4. KFT………………………..

5. Lipid Profile ………………….… 6. HBsAg …………………………..

7. Anti-HCV ………………………….. 8. Urine R/E :……………Urine M/E……………

9. Chest X-Ray :……………………….. 9. E.C.G.: …………..…………………

10. Ultrasonography Abdomen …………………………..

Remarks of Examining Medical Officer :

MEDICAL OFFICER CHIEF MEDICAL OFFICER

You might also like