Medical Report |
||
|---|---|---|
| Serial No | ||
|
Last Name: ............. Height: ........Ft.....In........ Sex: ............. Age: ............ Passport No: ............. Position applied for: ................. History of any significant post illness including: 1.) Psychotic and neurological disorders (Epilepsy. depression. Schizophrenia........... 2.) Allergy 3.) Others |
First Name :........... Wt...... Lbs...... Status : ........ Nationality : ........ Place of issue : .......... Recruiting Agency ......... |
|
| I hereby permit the………………..and the undersigned physician
to furnish such
information the
company pertaining to my health status and other pertinent and medical findings and do
hereby release them from any and all legal from my employment benefits and
claims. Signature of Examinee ………………………. |
|---|
| TYPE OF MEDICAL EXAMINATIONS | RESULTS |
|---|---|
| Rt
EYE ................ Lt |
|
| Rt
EAR ................ Lt |
|
| SYSTEM EXAM :
CARDIO-VASCULAR B.P............... HEART............... |
|
| RESPIRATORY SYSTEM :
LUNGS............... CHEST X-RAY |
|
| GASTRO INTESTINAL TRACK
ABDOMEN OTHERS |
|
| HERNIA |
|
| VARICOSE VEINS |
|
| EXTREMITIES |
|
| DEFORMITIES |
|
| SKIN |
|
| VENEREAL DISEASES CLINICAL |
|
| C N S |
|
| PSYCHIATRY |
| TYPE OF LAB INVESTIGATIONS | RESULTS |
|---|---|
URINE SUGAR ALBUMIN BILHARZIASIS (IF ENDEMIC) |
|
STOOL ROUTINE 1. HELMINTHES 2. GIARDIA 3. BILHARZIASIS (IF ENDEMIC CULTURE) 4. SALMONELLA SHEGELLA V CHOLERA (IF ENDEMIC) |
|
BLOOD HAEMOGLOBIN THICK FILM FOR 1. MALARIA 2. MICRO FILARIA SEROLOGY 1. F. B. S 2. L. F. T, S 3. CREATININE ELISA 1. HIV 1.2 TEST 2. HBs Ag 3. Anti HCV VDRL TPHA (IF VDRL POSITIVE) |
|
| PREGNANCY TEST |