Appx ’A’

BMS/27201602709/25-26

PRIMARY MEDICAL EXAMINATION REPORT

(for school admission in boarding)
(to be completed by a Pediatrician with a PG Degree or a Medical Officer from a Government Hospital.)

1. Exam No: _________ 2. Student Name: __________________________________________

2. Father’s Name: _________________________________ 4. Date of Birth: ______________

3. Class:_________ 6. Permanent Address: __________________________________________

_______________________________________________________________________________
_______________________________________________________________________________
7. Identification Marks:-
(a)
(b)

8. Personal Statement:-
(a) Family History.
If Alive If Expired
Relation Died
Age(Yrs.) Health Cause of Death
(Yrs)
Father
Mother
Brother/Sister
Wife
Daughter
Daughter
Hypertension Heart Diabetes Bleeding Mental Night
Any Family History of Disease Disorder Disease Blindness

(b) Personal History.

Have you suffered from any of the following illness/condition?
Illness (Yes/No) Illness (Yes/No)

Chronic Bronchitis/ Asthma Discharge from ears

Pleurisy/ Tuberculosis Any other Ear Disease

Rheumatism/Frequent Sore Throats Frequent Cough & Cold/ Sinusitis

Chronic Indigestion Nervous Breakdown/ mental illness

Kidney/ Bladder trouble Fits/ Fainting Attacks

Jaundice Severe head injury

Air, Sea, Car, Train Sickness

Page 1 of 5
 Appx ’A’ (Cont.)
BMS/27201602709/25-26
Illness (Yes/No) Illness (Yes/No)

Night Blindness

Laser treatment/Surgery for Eye

Any other Eye disease

Have you ever been admitted in hospital for any illness, operation or injury?

Any other information you can give

about your health?

I hereby declare that I have answered all questions about my family and personal health and that the
information given is true to the best of my knowledge.

(c) We further certify that we understand:-

(i) My son will be medically examined according to the medical standards

required for admission to Bhonsala Military School, Nashik.

Signature of the Parent Signature of the Candidate

Name : ___________________ Name : ______________________

9. PHYSICAL DEVELOPMENT

(a) Height without shoes ……………………… CMs.

(b) Weight

(i) Actual ……………… KGs (ii) Acceptable ……………….. KGs (as per BMI)

(c ) Any other relevant observation.

(d) Evidence of Skin disease if any.

10. MENTAL CAPACITY AND EMOTIONAL STABILITY.

(a) Speech

(b) Evidence Suggesting –

(i) Mental Backwardness (ii) Emotional Instability

11. LOCOMOTION SYSTEM

(a) Upper Limb (b) Lower Limb (c) Neck (d) Trunk

Page 2 of 5
 Appx ’A’ (Cont.)
BMS/27201602709/25-26

12. TEETH

(a) No of dental points (b) Condition of Gums.

(c ) Evidence of malocclusion

13. EYES R L CP

(a) Distant vision

(i) Without Glasses

(ii) With Glasses

(b ) Near Vision N N

(c ) Any evidence of trachoma or its complications or any other disease:-

14. ENT (a) Right Ear

(b) Left Ear

( c ) Any evidence of Otitis media

(d) Nose

(e ) Throat

15. Chest Examination: Measurement

(a) Full Expiration ………………. Cm

(b) Range of expansion …………….cm

(c ) Abnormalities if any :

16. CARDIO VASCULAR SYSTEM.

(a) Pulse : ……………….. /min (b) BP : …………………… mm of Hg.

(c ) Heart Sounds

(d ) Murmur

(e ) Blood Examination

(i) HB % …………………………..
(ii) Blood Sugar F ………… PP ………..
(iii) Blood Urea …………………………..
(iv) Creatinine …………………………..

(f) X –Ray Chest

(g) ECG

Page 3 of 5
 Appx ’A’ (Cont.)
BMS/27201602709/25-26

17. ABDOMEN

(a) LIVER (B) SPLEEN (C) HERNIA (D) HYDROCELE

18. GENITO URINARY SYSTEM:

URINE (a) Albumen…………………. (b) Sugar ………………….. (c) Specific Gravity…………………….

Abnormalities/Evidence of STD………………………………………………………………………………………………….

19. SLIGHT DEFECTS NOT SUFFICIENT TO CAUSE REJECTION:

20. HIV Status

21. IMMUNIZATION STATUS

(a) Tetanus

(b) Typhoid

(c) COVID-19

22. In your opinion is the candidate FIT to undergo Military Training ………………….. (Yes/No).

Place:
(Signature of Pediatrician / Medical Officer)
Date: Name
Degree
Registrations Number

Page 4 of 5
 Appx ’B’
BMS/27201602709/25-26

MEDICAL FITNESS CERTIFICATE

1. This is to certify that Name ___________________________________ _____________

S/O of ________________________________( name of Father) by the standard laid in
Bhonsala Military School (BMS) , Nashik admission process as per Appx ‘A’ and found his medically
fit to take admission for the academic year 2025-26 / military training / Parasailing to be held at
BMS, Nashik From 01 JUN 25 to 30 APR 26.

2. The basic medical parameters as on __________________ areas under :-

(a) BP
(b) Pulse
(c) Suitability from Cardiac point of view
(d) Whether any spinal Injury?
(e) Any history of Epilepsy/seozires?
(f) Eye Sight _____________.
(g) History of any past injury.

3. The indl has been vaccinated against Tetanus, Typhoid, smallpox, Cholera, Dengue, and
COVID-19.

4. He has been tested for COVID-19 on _______________ and his report is ______________.

5. The present medical cat of the indl is ________________ . (Fit / Unfit)

Place:
(Signature of Pediatrician / Medical Officer)
Date: Name
Degree
Registrations Number

COUNTERSIGNED BY THE COMMANDANT OF THE SCHOOL

Date :
Place:

Page 5 of 5