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VIPASHA PHARMACEUTICALS, 8- IND.AREA, SHAMSHI.

Medical Certificate for Workers/ Employees


Name: Age & Sex: Address: Signature of the Worker/ Employee Is the person to the best of your judgement subject to epilepsy, vertigo or any mental ailment likely to decrease his efficiency? Does the person suffer from any heart or lung disorder which might interfere with the performance of his duties? Is there any defect of vision? If so, has it been corrected by suitable spectacles? Can the person suffer from a degree of deafness which would prevent his/her hearing the ordinary sound signal? Does the person suffer from night blindness? Has the person any deformity or loss of membrane which would interfere with the efficient performance of his duties? If so, give details. Does he show any evidence of being addicted to excessive use of alcohol, tobacco or drugs? Does he/she suffer from attacks of loss of consciousness from any cause? Is he/she suffering from any defect in movement, control of muscular power on either arm or leg? Is he/she a mentally ill person? Does he/she suffer from any other disease or disability likely to cause him some harm? Is he/she in your opinion generally fit as regard to, Bodily health Eye sight Mental ability Hearing ability The person, in my opinion is: YES / NO

YES / NO YES / NO

YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO

YES / NO YES / NO YES / NO YES / NO FIT / UNFIT

Signature Name and Designation of the Medical Officer Date: Place:

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