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Letter Head
NAME…………………………………………………………………………………………
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AGE……………… ID.
NO………………………………………………………………………………………………
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ADDRESS………………………………………………………………………………………
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BLOOD
GROUP…………………………………………………………………………………………
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EYES VISUAL
ACUITY………………………………………………………………………………………
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COLOURED BLIND……………………………………………………………………
VISUAL………………………………………
CARDIAC
NORMALITY/HISTORY……………………………………………………………………
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MALARIA……………………………………………………………………………………
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TUBERCULOSIS……………………………………..ANY
ALLERGY…………………………………………………………….
ACCIDENT
HISTORY…………………………………………………………….HERNIA………………
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SKIN…………………………………………………….ANEMIA
HISTORY……………………………………………………..
PHYSICAL
DEFORMITIES………………………………………………………………………………
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GENERALCOMMENTS………………………………………………………………………
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DESIGNATION……………………………………………………………
DATE………………………………………………………