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CSB Certificate of Medical Examination

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26 views1 page

CSB Certificate of Medical Examination

Uploaded by

Clinton
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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CSB 31

Stocked by Govt. Printer


200 x 9/87 p/p4
APPENDIX III(Vide General Order 9( a))
REPUBLIC OF ZAMBIA
FORM OF CERTIFICATE OF MEDICAL EXAMINATION

To (1) ……………………………………………………………………………………
I hereby certify that I have this day examined (2)………………………………………
………………………………………………………………………………………….
Candidate for employment as (3)………………………………………………………
And my opinion is that he/she is ……………………….for service in the Republic of Zambia.
………………………….
Medical officer
Date………………………………………….
Station……………………………………….
(1). To the head of department in charge of candidate.
(2) and (3) to be filled in by the Department applying for a medical Certificate.
(4) Medical Officer to insert Fit or Unfit or Unit as the case may be.
Reverse to be completed on Copy for DMS only.

This form may be obtained from the Director or Medical Services Lusaka.

TO BE COMPLETED ON COPY FOR DMS ONLY


Age……………………………..Height………………………Weight…………………
Physique………………………………………Mental State……………………………
Previous
illnesses…………………………………………………………………………………………………
………………………………………………..
RESPIRATORY SYSTEM: Girth……Full respiration………….Full expiration……….
(a) Any abnormality or Clinical Examination…………………………………………
………………………………………………………………………………………….
(b) X-ray of chest where possible……………………………………………………...
CARDIO VASCULAR SYSTEM:
(a) Rate and quality of pulse……………………………………………
(b) Any cardiac abnormality………………………………………………
(c) Blood pressure………………………………………………………
(d) Any varicose veins………………………………………………….
ALLIMENTARY CANAL AND ABDOMEN:
(a) Any symptoms………………………………………………………
(b) Condition of mouth, teeth and tonsils……………………………….
(c) Any abnormality of liver or spleen………………………………….
(d) Any hernias………………………………………………………….
(e) Any hemorrhoids……………………………………………………..
GENITO URINARY SYSTEM
(a) Any symptoms or abnormality………………………………………
(b) Urine…………..SG……………..Reaction………..ALB………….Sugar………..
INTEGUMENTARY SYSTEM
(a) Any eruption or ulcer…………………………………………………
ONS
(a) Any symptoms………………………………………………………..
(b) Patellar reflexes….……………………………………………………
(c) Pupils…………………………………………………………………
(d) Hearing……………………………………………………………….
(e) Speech………………………………………………………………..
REMARKS:
…………………………………………………………………………………………………………
…………………………………………….
Medical Officer
Date…………………………………………
Station………………………………………

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