Doc Ref No: SPI-HSE-FR-05

CERTIFICATE OF MEDICAL EXAMINATION Revision No: 01

(PRE-EMPLOYMENT) Release Date:20/11/2018

Examination Date Certificate Serial No.

AA. Details of person
Contractor’s Name:
Name of employee Father’s name
Identification marks I. Date of birth / Age
II. Gender □Male □Female
Address

Medical History □ Accident □ Surgery □ Allergy□ Any Amputation □ Any Others (specify…)

Other diseases □Diabetics □Hypertension □Heart Disease □BP □Asthma □TB □ Convulsion

Personal habit □Smoking □ Alcoholic □ Tobacco chewing □Others (Pl. specify…)

BB. Clinical Examinations
Height (in m) Chest Inspiration (cm)

Weight (in kg) Chest Expiration (cm)

Pulse (per min) Blood Pressure (mmHg)

Blood Group Rh Factor

□ Adequate arm □ Adequate leg and foot □ Spine –adequately □ Mental alertness: eye hand
function and grip function…………………(Yes/No) flexible for construction and foot coordination
……………… (Yes/No) job…………… ……(Yes/No) ……………………..(Yes/No)
□ Adequate eyesight □ Adequate hearing
……………..(Yes/No) ……………………….(Yes/No)

Contagious Disease / Skin disease (if any):

Audiometry /Eye /test is mandatory for equipment operators. Report attached : □ Yes □ No

I hereby certify that I have personally examined (NAME) ________________________

Who is desirous of being employed in building and construction work and that his/her is nearly as can be
ascertained from my examination is ________YEARS and that he/she is fit for employment in
_______________________________( Name of Site ) as an adult.

Reason for
REFUSAL of Certificate _______________________________________
Certificate being revoked ________________________________________

(Signature with date)

Signature /Left hand Thumb Name & designation of the MBBS Medical Practitioner Impression of
applicant
Seal

Seal with registration number of the examining doctor