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Form Medical Physical Fitness Certificate Template

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rajrajit1212
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21 views1 page

Form Medical Physical Fitness Certificate Template

Uploaded by

rajrajit1212
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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FORM OF MEDICAL PHYSICAL FITNESS

CERTIFICATE
I, Dr. ___________________________, do hereby certify that I have examined Mr./Mrs.
___________________________, resident of ___________________________, and cannot
discover that he/she has any physical deformity, blindness of one or both of the eyes, or deafness,
stammering or stuttering or other defect of speech. I further certify that I cannot discover that he/she
has any disease, constitutional affliction, or bodily infirmity.

His/Her age is _______ years only,


According to his/her appearance _______ years.

I certify that he/she has marks of smallpox/vaccination.

The following measurements are:


1. Weight: _______ kg
2. Height: _______ cm

CHEST MEASUREMENTS
a) On full expiration: _______ cm
b) On full inspiration: _______ cm
c) Difference: _______ cm

3. Activeness of vision: ___________________________


4. Fitness for outdoor work: ___________________________

Personal marks of identification:


1) ___________________________
2) ___________________________

Station: ___________________________
Date: ___ / ___ / _______

Signature: ___________________________
Designation: ___________________________
Seal:

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