\CJ __.

APPENDICES

Appendix- 'A'

DECLARATION BY THE OFFICIAL TO BE EXAMINED FOR SHAPE CATEGORISATION

1 Were you examined for any major ailment or Please record your
hospitalized during last one year? answer:
2 Are you a patient of :
a. Hypertension (High Blood Pressure)
b. lschaemic heart disease?
c. Diabetes Mellitus?
d. Chronic cough/ Br. Asthma/ COPD?
e. Epilepsy (Fits)
f. Persistent Headache
a
D" 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 Your (a) Appetite
(h) 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 under orders
of transfer? If so your
a. Previous Unit
b. New Unit

It is further certified that the above facts stated by me are true 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 Rank

EMPLOYEE CODE:
Designation:
Unit:
 APPENDIX-'B'

MEDICAL EXAMINATION PROFORMA FOR POLICE OFFICERS

1. Name
2. ID 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 I 0. Ratio (8/9)
girth:

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 if any applied and result there of:

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

H HEARING

i) Normal in both ears. v) Auroscopy-

ii) Moderate defect in one ear. vi) Renriie's Test-
iii) Partial defect in both ears. vii) Weber's Test-
iv) Any other combinations. viii) Audiometry (if indicated)

CATEGORISATION: H-1 I H-2 I H-3

'A' -APPENDAGES

i) Upper limb
ii) Lower limb
iii) Any loss/ infirmity in any joint or part must be indicated in detail

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

A-(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
lcterus Respiration
Oedema
Clubbing
Koilonychia
Lymph glands Tonsils
palpable
JVP Teeth/Denture
Thyroid Throat
Spleen Liver
c.v.s. E.C.G. {Required after age
of 45 years)
5 1 Blood Sugar(lf applicable):
s 2 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-
Cerebell ir Sign Go'::er'c; Sihn
 Sensory System- -2.'L -
Reflexes- Romberg's sign- SLR Finger-Toe

Test

Skull & Bone

Abdomen: General: Any mass palpable any other abnormality.
Piles I 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 45yrs.
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: Pl P2 P3

"E" Factor (Eye sight/ Vision)

(a) Distant Vision

(b) Near Vision
( c) Colour Vision
(d) Field of Vision
( e) Any other Pathology
(~ IOL

CATEGORISATION: El E2 E3

FINAL CATEGORIZATION

ADVICE/ EMPLOY ABILITY

RESTRICTION(S) IF ANY

(NAME OF MEDICAL OFFICER):/ BOARD MEMBERS DESIGNATION/ UNIT