KALPATARU POWER TRANSMISSION LTD.

PRE-EMPLOYMENT MEDICAL EXAMINATION

 

Strictly Confidential
 

‘KALPATARU Power Transmission Ltd 
PRE‐EMPLOYMENT MEDICAL EXAMINATION REPORT 
 

Medical Check‐up for  

a. CBC 
b. Blood Group 
c. Urine – routine 
d. X-ray-Chest 
e. E.C.G. & Physical check-up 

Date :  _______________________      Signature _______________________ 

   
 KALPATARU POWER TRANSMISSION LTD.
PRE-EMPLOYMENT MEDICAL EXAMINATION
 

  PART - I
( To be filled-up by the Applicant)
A. a Name ( in full) : ___________________________________________________

b Date Of Birth: ___________________________________________________

c Marital status: ____________________________________________________

d Sex: _____________________________________________________

e No.of. Chilldren: __________________________________________________

f Identification Marks: _______________________________________________

B. SR Have you ever had If yes, year No SR Have you ever had If yes, year No
1 Tonsils removed 15 Loss of memory
2 Appendix removed 16 Loss of consciousness
3 Other Operations 17 Heart murmer
4 Typhoid 18 Hyper-tension
5 Pneumonia 19 Low BP/ High BP
6 Malaria 20 Drug or serum reaction
7 Hernia 21 Drug or Narcotic habit
8 Dysentary-amoebic/bacilliary 22 Nausea, Nervous breakdown
9 Chronic indigestion 23 Bowel trouble
10 Jaundice 24 Deafness or ear discharge
11 Tuberculosis 25 Eye trouble
12 Asthma 26 Diabetes
13 Veneral disease 27 Severe injury/Accidents
14 Fits or convulsions 28 Skin trouble

C. SR Have you ever: YES / NO SR Have you ever: YES / NO

1 Worn glasses or contact lenses 4 Worn false teeth

2 Worn a hearing aid 5 Lived with a person suffering from tuberculosis

3 Worn a brace or back support 6 Sluttered or stammered

7 Been denied employment for health reasons

Have you been immatured

Have you been immatured against the
If yes , against the following
D. SR following diseases ? If so , please state the Yes/No SR Yes/No If yes , When
When diseases ? If so , please state
year of immunization.
the year of immunization.

1 Smallpox 4 Typhoid
2 Cholera 5 Polio
3 Tetanus

E. During the previous twelve months, have you been on any special diet or medication ? If so, please enumerate details.

F. Family History:
If yes,state
Cause/Yr.  Have any of these members of your family had :
SR Realation & Age State of Health relationship
of death
1 Father A heart attack
2 Mother A stroke(paralytic)
3 Brothers Diabetes
Veneral disease
Epilepsy
4 Sister Tuberculosis
Allergies/Asthma
Committed suicide

I hereby declare that my answers to the above quesations are true and correct and that I have not wilfully withheld any fact or information about my
state of health that would , if disclosed at anyh time, be the factor for termination of my employment with the company

Signed in my Presence Signature

Date
Signature of Physician
 KALPATARU POWER TRANSMISSION LTD.
PRE-EMPLOYMENT MEDICAL EXAMINATION
PART II

[ To be filled by Physician] 
 

A. General   
 
a) Height ________ cms.      b) Weight _______kgs.   c) Blood pressure ______    
d)  Chest __________cm 
 
B. Vision   C. Ears 
   
Without glasses R6/‐ ______L6/___________  1. Pain _________________ 
With glasses R6/‐ _________L6/___________  2. Discharge____________________ 
Colour Vision R__________L______________ 
3. Deafness R __________L______________ 
Any other defects ______________________ 
4. Middle ear disease_________________   
 
5. Is hearing normal in both ears? _________ 
 
D. Nasal  E. Throat and Mouth 
   
1. Running _________________  1. Condition of tonsils _________________ 
2. Septum____________________  2. Condition of teeth____________________ 
3. Sinuses _______________________  3. Condition of gums___________________ 
4. Any other defects_________________   4. Caries  ____________________________   
  5. Pyrrhoea__________________________ 
6. Congestion _________________________ 
7. Dentures ___________________________ 
 
F. Skin, Lymph Glands, Nails  G. Respiratory System  
   
Any abnormality   1. Character of respiration _______________ 
  2. Respiration  per  minute_____________ 
3. Percussion note___________________ 
4. Any adventitious sounds _______________ 
5. Pain__________________________ 
6. Cough _________________________ 
7. Sputum ___________________________ 
 
Cardiovascular System  H. Nervous System 
1. Pulse rate per minute _______________   
2. Regularity of  pulse_____________  1. Reflexes_______________ 
3. Heart Murmers___________________  2. Tremors____________ 
4. Blood Pressure_______________  3. Sleep___________________ 
5. Pain Retrosternal_____________  4. Memory_______________ 
6. Dyspnoea _________________________ 5. Any abnormality_____________ 
7. Any other abnormality ______________   
   
 KALPATARU POWER TRANSMISSION LTD.
PRE-EMPLOYMENT MEDICAL EXAMINATION
PART II
[ To be filled by Physician] 
 

I. Alimentary System:   J. Musculo –Skeletal  System 
1. Pain(abdomen) _______________   
2. Heart burn_____________  1. Spine_______________ 
3. Dyspepsia___________________  2. Bones____________ 
4. Flatulence_______________  3. Joints___________________ 
5. Liver____________  4. Flat Feet_______________ 
6. Spleen _________________________  5. Any abnormality_____________ 
7. Tenderness in abdomen _____________   
 
K. Genitals and Rectal  L. Screening / X‐Ray 
  _____________________________________ 
1. Hernia Orifices_______________   
2. Hydrocele R____________   
3. Fissures___________________   
4. Fistulae_______________ 
 
M. Extremities   N. Results of ECG  
___________________________________ 
___________________________________ 
 
O. Are there any other diseases/abnormalities  P. Results of Pathological Tests 
or deformities? If so, please list details    
________________________________  1. Blood ____________(papers enclosed) 
_______________________________  2. Urine ____________(papers enclosed) 
3. Stool ____________(papers enclosed) 
4. Blood Grouping __________________ 
 
Q. General Remarks ( if any) 
 
 
 
 

I Dr. _________________ have examined __________________ and in my opinion he/she

is :
( ) Fit for employment
( ) Unfit for employment

( if unfit-reason)

Date : _______________ Signature : ____________________________