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Proforma For Medical Certificate of Fitness - From MBBS Qualified Doctor

A medical proforma

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silanan178
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292 views1 page

Proforma For Medical Certificate of Fitness - From MBBS Qualified Doctor

A medical proforma

Uploaded by

silanan178
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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PROFORMA FOR MEDICALCERTIFICATE OF FITNESS FROM MBBS QUALIFIED

DOCTOR (ON THE LETTER HEAD OF THE HOSPITAL/ INDIVIDUAL DOCTOR)

Name ……………………………………………………….

Father’s Name ……………………………………………………….

Name of Doctor ……………………………………………………….

Medical History

(a) Blood Group

(b) Date of Vaccination:

(i) Chicken Pox ……………………………

(ii) Hepatitis B ……………………………

(iii) Covid – 19 -> Date of Dose 1 ……………………………

Date of Dose 2 ……………………………

(c) Injuries in the Recent Past:

(d) Allergies to drugs, medicines or any other thing like food item etc. (This must be declared
immediately on arrival)

(e) History of current medication (attach sheet if required)

(f) Certificate by doctor to state that the student is free from any communicable disease and is
not suffering from or ever suffered from diseases which need immediate medical attention
like congenial heart disease, rheumatic septal deficiency, bronchial asthma, epileptic fits,
diabetes mellitus or psychiatry related diseases etc.

Note: If so then the same must be mentioned / declared with the medical officer of the Institute
immediately at the time of joining to enable quicker and suitable response in case of
emergency

Signature of Student Signature of Parent Signature of Medical Officer

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