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Medical Fitness Certificate

The document is a Medical Fitness Certificate template that collects personal information such as name, age, weight, height, and medical history. It includes sections for assessing physical and mental health, including details on vision, hearing, disabilities, and any significant diseases. The certificate concludes with a certification statement by the examining physician, along with space for the place and date of examination.

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apollopccmadanapalle
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324 views1 page

Medical Fitness Certificate

The document is a Medical Fitness Certificate template that collects personal information such as name, age, weight, height, and medical history. It includes sections for assessing physical and mental health, including details on vision, hearing, disabilities, and any significant diseases. The certificate concludes with a certification statement by the examining physician, along with space for the place and date of examination.

Uploaded by

apollopccmadanapalle
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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MEDICAL FITNESS CERTIFICATE

Name: ...………………………………………………

Father`s Name: …………………………………………………

Gender: …………………………………………………

Age: …………………………………………………

1. Weight: ………………(Kgs) Height …………………..(cm) BP: …………………………………………

2. Lungs: ………………………………………………. Blood Group: ………………………………………

3. Heart: ………………………………………………..

4. Vision: Left Eye …………………. Right Eye……………… Details of Glasses (if Worn)………….

5. Hearing: ……………………………………………………………………………………………………………………..

6. Any impediment in speech: ………………………………………………………………………………………..

7. Any Disability: ……………………………………………………………………………………………………………..

8. Any Neurological / Psychiatric Disease,(if, yes, Please give deatiles) ……………………………

9. Any Significant disease diagnosed in the past: ……………………………………………………………..

10. Vaccinated (Yes/No/Partially): ………………………………………………………………………………………

11. Taking any medicine on a regular basis (if yes, please give deatiles):……………………………..

12. Allergies if any: ………………………………………………………………………………………………………………

13. Any communicable/contagious disease: ………………………………………………………………………..

14. Mark of identification: …………………………………………………………………………………………………..

15. Family History HT/DM/IHD

Personal History : Alcohol Y / N

Exercise : Regular Y / N

I certify that I have examined Mr/Ms …………………………………Son/Daughter of

………………………………..and could notice that he/she has any physical or mental disease.

Place:

Date:

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