CONFIDENTIAL

PROFORMA FOR MEDICAL EXAMINATION

NAME :________________________________. MOBILE :_________________. DATE:_________________

DESIGNATION :_________________________.AGE :__________________. SEX :_________________

DIVISION : _____________________________.

PRESENT COMPLAINTS : _________________________________________________________________

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PAST HISTORY : ________________________________________________________________________

PAST HISTORY OF SURGERY : ____________________________________________________________

FAMILY HISTORY : ______________________________________________________________________

PERSONAL HISTORY :
Diet :__________________________________. Tobacco : _____________________

Appetite : __________________________________. Alcohol : _____________________

Bowel Habits :__________________________________. Marital Status :_____________________

Micturation : _________________________________. Children : _____________________

Menstruation : _________________________________. Sterilization : _____________________

OCCUPATIONAL HISTORY :
Sedentary / Active / Manual : _______________________. Exercise : _____________________

GENERAL EXAMINATION :
Height : cms. Ears : RT. :__________. LT. __________

Weight : Kgs. Eyes : With Glasses / Without Glasses

Pulse : / min. D.V. : RT. _______LT. ________

B. P. : / mm of Hg N.V. : RT. _______LT. ________

Colour Blindness : Nose :

Lymph nodes : Throat :

Hernia : Teeth :

Phymosis : Skin :

Other relevant points :

SYSTEMIC EXAMINATION :

Cardio – Vascular System : __________________________________________________________

Alimentary System : __________________________________________________________

Respiratory System : __________________________________________________________

Central Nervous System : __________________________________________________________

Chest X Ray : __________________________________________________________

ECG : __________________________________________________________

SGPT : __________________________________________________________

BUL : __________________________________________________________

INVESTIGATION :

Haemogram : ____________ gms% W.B.C. Count. Total :_____________ / cmm

Differential : P ___________ L __________ M ______________ E ______________

Blood Sugar ( R ) : ___________ mg./dl. Blood Group :_____ Rh ______________

Urine Analysis ( R ) : Alb. __________ Sugar : _____ PUS Cells : _______

Epi Cells _____ RBCS : ________________________

REMARKS :
_______________________________________________________________________________________

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Contact No. Clinic :___________________ Dr Name: _______________________________

Resi. :____________________ Qualification: ____________________________

Mobile : ___________________ Reg. No. : _______________________________