CARE MEDICAL
CLINIC
Services offered: General medicine, Admission, Laboratory, Pediatric, HIV Testing,
Guidance and Counseling, Family planning, Dispensary, Post Abortion Care, Minor Surgeries,
Antenatal Services, Maternity, Geriatrics, etc.
MEDICAL EXAMINATION FORM
SECTION A. (To be filled in the presence of the examining registered
medical Practitioner)
Candidate’s consent: I Names) _________________________________ consent to
having this report communicated confidentially
to____________________________
(Institution requiring the report)
Signature of the
candidate_____________________Date__________________________
SECTION B. (To be filled by a registered medical practitioner)
1. Names of Candidate ( Surname first)---------------------------------------------
Age--------------- Sex-----------------Address--------------------------------------
2. Medical history (In this and subsequent sections elaboration
may be made on the attached page)
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3. Physical examination
[a] General appearance [tick] Good Fair Poor
[b] Blood pressure----------------[c] Weight-------- [Kg] [d] Height------------
4. Signs of disease in specified systems [“No” or “yes” if yes
elaborate]
I. Skin -------------------------------------------------------------------------
II. Musculo-skeletal------------------------------------------------------------
III. Cardio – Vascular-----------------------------------------------------------
IV. Respiratory------------------------------------------------------------------
V. Gastro- intestinal-----------------------------------------------------------
VI. Uro-genital-------------------------------------------------------------------
VII. Central Nervous [CNS]-----------------------------------------------------
VIII. Special organs----------------------------------------------------------------
- Eyes----------------------------------------------------------------------
- Ears----------------------------------------------------------------------
- Lymph nodes.----------------------------------------------------------
- Endocrines--------------------------------------------------------------
Lab tests done [if indicated]
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Any other observations--------------------------------------------------------------------
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5. Medical examiner’s recommendation [Tick and comment where
appropriate]
[a] Recommended with no reservations
[b] Recommended with the following comments
I. ----------------------------------------------------------------------------
ii. ------------------------------------------------------------------------------
Iii----------------------------------------------------------------------------------
[c] Not recommended because of the following reasons
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Name of the examining registered medical practitioner. -----------------------------
Qualifications-----------------------------------------Signature---------------------------
Address------------------------------------------------Date----------------------------------
Official stamp
