PRE-EMPLOYMENT MEDICAL CHECK-UP FOR CONTRACTOR EMPLOYEES

TATA MOTOR LIMITED – PV SANAND

Examination Centre:- Date Of Birth: Date of Examination:

Age: ________________ Years

Surname : Name : Father’s name:

Contractor Name: Aadhaar Number:

TO BE FILLED IN BY THE CANDIDATE

PAST & PRESENT ILLNESS - WRITE YES OR NO
ASTHAMA HEART DISEASE

T.B MAJOR INJURIES PHOTO

EPILEPSY PSYCHIATRIC ILLNESS

FRACTURE ´ OPERATION

POLIO Deaf/ decreased hearing

Dumb Loss of vision/decreased vision

Any illness since birth High BP/ Diabetes

Identification mark
Taking regular medication for illness
If yes, please give details: …………………………………………………………………….
Signature of candidate

FOR OFFICE USE ONLY

Height Cms CLINICAL EXAMINAION

Weight Kgs Build : NAILS:
BMI :
Waist/ hip ratio: PULSE :
VISION
Rt Eye Lt Eye BP : mm Hg
Without D.V 6/ 6/
Glasses CVS :
N.V N N
With D.V 6/ 6/ RS :
Glasses
N.V N N PA :
Power of
Glasses / MUSCULO SKELETAL :
Contact
Lenses SKIN :
SQUINT
PRESENT ABSENT GENITO –URINARY :
IDENTIFICATION OF INDIVIDUAL COLOURS
NORMAL DEFECTIVE
ANY OTHER:
ISHIHARA CHART (17/21)
NORMAL DEFECTIVE
______________________________________________________________
TITMUS FOR DRIVERS
Medical Fitness (Valid for One Year) : FIT FOR EMPLOYMENT / UNFIT
Binocularity:
Stereo Depth:
Peripheral vision:
Muscle strength: Lateral/ Vertical Phoria
Night Vision
Signature & Stamp of Examining Doctor
HB RBS