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AME-New Proforma-1

The document contains two appendices related to medical examinations. Appendix A is a declaration form for an individual to declare their medical history, including any hospitalizations, chronic conditions, symptoms, habits, and previous injuries or surgeries. Appendix C is a medical examination proforma that collects an individual's personal details, conducts assessments of their psychological, hearing, appendages, physical, and eyesight attributes, and determines a final medical categorization and any employment restrictions. The proforma examines various body measurements, systems, and can request investigations like ECG, blood tests, and x-rays to make the categorization determination.

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KRISHNA MOHAN PANDEY
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780 views4 pages

AME-New Proforma-1

The document contains two appendices related to medical examinations. Appendix A is a declaration form for an individual to declare their medical history, including any hospitalizations, chronic conditions, symptoms, habits, and previous injuries or surgeries. Appendix C is a medical examination proforma that collects an individual's personal details, conducts assessments of their psychological, hearing, appendages, physical, and eyesight attributes, and determines a final medical categorization and any employment restrictions. The proforma examines various body measurements, systems, and can request investigations like ECG, blood tests, and x-rays to make the categorization determination.

Uploaded by

KRISHNA MOHAN PANDEY
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Appendix-‘A’

DECLARATION BY THE OFFICIAL TO BE EXAMINED FOR SHAPE


CATEGORIZATION

1. Where you examined for any major ailment or Please record your answer
hospitalized during last one year?
2. Are you a patient of :-
a. Hypertension (High Blood Pressure)
b. Ischaemic Heart Disease
c. Diabetes Mellitus.
d. Chronic Cough/ Br. Asthma/ COPD.
e. Epilepsy (Fits)
f. Persistent Headache.
g. Mental instability.

3. Have you suffered from Giddiness at any time?


4. Have you suffered from Chest Pain/ Palpitation?
5. Did you ever suffered from Tuberculosis?
6. You (a) Appetite
(b) Sleep
7. Smoking habit (If yes, no of cigarettes per day)
8. Alcohol intake (If yes, average quantity per day)
9. Any accident/ injury/ major surgery undergone so
far?
10. Have you been transferred recently or undergone of
transfer? If so your
(a) Previous Unit
(b) New Unit

It is further certified that the above facts stated by me are to my best


knowledge and belief. I have not suppressed any fact concerning my health
condition ever in past and as is at present.

Place : Signature:

Date: Name :
IRLA/F.No. :
Designation :
Unit :

APPENDIX-‘C’
MEDICAL EXAMINATION PROFORMA FOR OFFICERS AND MEN IN C.P.M.F
1. Name :
2. IRLA/Force No. :
3. Age : 4.Sex : M/F
5. Height (Cms) : 6.Weight (Kg): 7.Chest (Not for ladies)
Body mass Index : - On Expiration :
- On full inspiration:
8. Abdominal girth : 9.Trans-trochanteric girth: 10. Ratio (8/9) :

S PSYCHOLOGICAL ASSESSMENT AS LAID DOWN


i) Any past history of psychiatric illness, if so details :

ii) Any history of breakdown/outburst or taking wrong decisions,


indecisiveness leading to public reaction or castigation of civil
authority.

iii) History of any alcoholic/drug abuse.

iv) History of Head injury/infective/metabolic en-cephalopathy.

v) Objective Psychometric scale of any applied and result there of.

CATEGORISATION: S-1 / S-2 / S-3 / S-4 / S-5 /

H HEARING
i) Normal in both ears. v) Auroscopy-
ii) Moderate defect in one ear. vi) Rennie’s Test -
iii) Partial defect in both ears. vii) Weber’s Test -
iv) Any other combinations. viii) Audiomentry (if
indicated)

CATEGORISATION: H -1 / H-2 / H-3

A APPENDAGES
i) Upper limb
ii) Lower limb
iii) Any loss/infirmity in any joint or part must be indicated in details.

CATEGORISATION: A-1 (U), A-2(U), A-3 (U)


A-1 (L), A-2(L), A-3 (L)
P: PHYSICAL
General examination:
Distance covered in 12 minutes run/walk (Meters)
Body built : BP (mmHg) :
Tongue : Pulse/mt :
Anaemia : Temp (c). :
Cyanosis :
Icterus : Respiration :
Oedema :
Clubbing :
Koilonychia :
Lymph glands palpable: Tonsils :
JVP : Teeth/Denture :
Thyroid : Throat :
Spleen : Liver :
C.V.S. : E.C.G.: Required after age of 45 years
S1 : Blood Sugar : if Applicable
S2 : Urine exam : In all cases
Hb % : In all cases
Murmur if any:

R-System: Any deformity of chest: Percussion


Breath sounds Adventitious sounds

C.N.S. Higher functions: Memory (Recent & Remote)


Intelligence
Personality
Orientation (time, place & person)
Cranial
Nerves
Meningeal Sign if any –

Motor System Nutrition of muscles Wasting-

Tone
Coordination
Abnormal movement/ fasciculation
Power
DTR
Plantar - Abdominal & Cremasteric
refl.-
Cerebellar Sign Gower’s Sign

Sensory System-

Reflexes - Romberg’s sign- SLR Finger –Toe

Test
Skull & Bone
Abdomen: General: Any mass palpable any other
abnormality.

Piles/Fissure - Fistula - Prolapse rectum

INVESTIGATION :
1. Hb %
2. Urine examination for all ages.
3. ECG after age of 45 years : Blood sugar if Applicable and for all
above 45 years.

4. Any other investigation as deemed necessary by examining Medical


Board i.e. X-Ray chest, Lipid profile, Glycosylated Hb etc.

I agree/ Don’t agree to undergo HIV test Signature –


CATEGORISATION: P -1 P-2 P-3

“E” Factor (Eye sight/Vision)

a) Distant Vision :
b) Near Vision :
c) Colour Vision :
d) Field of Vision :
e) Any other pathology :
f) IOL :

CATEGORISATION: E -1 E-2 E-3

FINAL CATEGORISATION

ADVICE/EMPLOYABILITY
RESTRICTION(S) IF ANY

SIGNATURE OF MEDICAL OFFICER SIGNATURE OF INDIVIDUAL


(NAME OF THE MEDICAL OFFICER) DESIGNATION/UNIT
WITH RUBBER STAMP

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