Name of the Candidate:-

Father’s Name:-
Sex:- Age:-
Date of Birth:-
(as per certificate submitted for proof of age)
Nationality:-
Address:-
Candidate’s photograph to be
countersigned by examining physician

Personal and Past History:-

1. Are you allergic to any medicine/other substance. History of allergic rhinitis /Bronchitis
Yes/No
2. Have you ever met with any accident leading to fracture of bone or other serious deformity.
Yes/No
3. Have you undergone any surgical operation for Hernia/Hydrocoele/or any major operation for
thoracic, neurological, orthopedic or abdominal conditions, If yes mention the nature of
Operation.
Yes/No
4. Have you ever suffered from convulsions/epileptic fits?
Yes/No
5. Are you suffering from any chronic disease like diabetics elitus, Ischaemic Heart disease, High
Blood pressure etc?
Yes/No
6. Have you suffered from any Menstrual/Gynecological problem.( Applicable in Female
candidates only)
Yes/No
7. Are you in habit of smoking or taking Alcohol or any other drug.
Yes/No.
8. Are you suffering/Have suffered from any infectious diseases like Pulmonary Tuberculosis,
Hepatitis B infection.
Yes/No

Signature of the candidate

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 Eye Examination (to be filled up by the Eye Specialist)

(a) Visual acuity

Right Eye______________________ with /without Glasses

Left Eye________________________with/without Glasses

(b) Power of Corrective Glasses

Right Eye _______________________
Left Eye __________________________
(c) Color Perception
Right Eye__________________________
Left Eye____________________________

Conditions for Fitness

• The colour vision should be normal as determined by Ishihara’s Test Chart.

• Acuity of vision without/with glasses should be 6/6 in each eye.
• The power of corrective glasses should not exceed +- 4.0 D(Spherical/Cylindrical combined)
• The Candidate should have binocular vision.
• The Candidate should not be suffering from night blindness like Retinitis Pigmentosa.

The Candidate is declared Fit/Unfit for Employment from Eye Examination point of view.

Signature of the Eye Specialist

Name___________________

Designation_______________

Office Address:_____________

___________________________

Medical Registration No._______

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General Clinical Examination (to be filled up by the Physician)

General Condition:-

Skin Condition:-

Visible Identification Marks (1)

(2)

Weight (in Kilograms)

Height (in centimeters)

Chest (Inspiration)- Cms

(Expiration)- Cms

Ears Nose Throat

Right

Left

Heart-

Blood Pressure-Systolic__________________________

Diastolic__________________________

Lungs-

Abdomen-Evidence of ascites/lump/tenderness

Liver-

Spleen-

Hydrocele/Hernia-

Congenital/Acquired Deformity or anamoluses

Remarks (Any Relevant findings)-like Clubbing ,Oedema ,Jaundice, cyanosis, Lymphadenopathy ,Palpable
Nodule/Lump.

Examination of CNS

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Examination of Locomotor System

Gait- evidence of Limping

Ability to Squat and to do sit-ups

Amputation/deformity/Loss of function of any digits/fingers/toes/joints or any part of upper and lower

extremities and spines.

The candidates is declared fit/unfit for Employment

Signature of the Examining Physician

Name_________________________

Designation_____________________

Official address:____________________

Date:___________ Medical Registration No.______________

Guidelines

Weight: 43.5 Kg is considered minimum weight for male candidates. Below 43.5 Kg is declared
underweight. For Female candidates the weight is 40 kg.

Height & Chest measurement: No minimum standard, no relation with weight.

Blood Pressure: Systolic Blood pressure not more than140 mm of Hg Diastolic Blood Pressure should not be
more than 90 mm of Hg.

If History/Clinical Examinations are suggestive of any disease, relevant investigation should be carried out.

Hernia/Hydrocele- candidates declared temporarily unfit till operated and cured.

Page 4 of 4