Send Medical Report along with Medical Examination Form to HR Department

MEDICAL EXAMINATION FORM

Pre-employment medical check up (To be filled by Doctor)
Name : PHOTO
Age: Sex:
Sent by: To:
For the Post of: Location:

Date of Birth Date of Examination

Contact No: Blood Group

Identification marks:
Past/ H : Pres/ H :
H/O epilepsy:

General Examination
Eyes : Colour vision :
Vision (with/ without glasses) : Near – R : Lt: Distance – R : Lt:
Height : (in cms) Weight : (in kg) Teeth : ENT :
Pulse : (Regular/ Irregular) Blood Pressure : (mm Hg)
Skin:

Systematic Examination
R. S. :
C. V. S : Heart Sounds Murmurs :
GI: Liver :
Spleen : C. N. S :

X- Ray Chest : ECG :

Stress Test : Audiometery :

Any other abnormalities/ Physically Handicapped:

Investigations : Pathology tests ( Abnormal findings) :

Sign of Examining Doctor: Name: Seal with Reg.No:

Fitness Certificate : (To be signed by Plant Doctor)

This is to certify that Mr. / Ms. / Mrs. _______has undergone Pre- employment medical examination and is
found FIT / UNFIT to join Katerra India Private Ltd.

Name, Stamp & Signature of Medical Officer