Annexure-H (FORM OF MEDICAL FITNESS CERTIFICATE)

Name -
Date of Birth -
Father/ Spouse`s Name -
Identification Mark -
Chest Size Inspiration - Expiration -
General Examination Build - Height - Weight -
Pallor - Icterus - Oedema -
CVS Heart Beat Rate - Rhythm -
Blood Pressure Sitting- Standing -
Respiratory System Breath Sounds
Added Sounds - Yes/ No
Per Abdomen Hepatosplenomegaly Yes/No Tenderness – Yes/No
Bowel Sounds Hernial Orifices -
CNS Motor System Power - Reflexes -
Sensory System Paraesthesia - Pins & Needles -
Vision VA - Color Vision -
Hearing Tuning Fork Test -
Present Medication
Past Medical History
History of Seizures Yes/ No. if Yes since years
Vertigo Test Positive/ Negative
Investigation Reports Hemoglobin - Blood Sugar (R) - Urine – R/M -

I have examined Shri / Smt. / Kumari .................................................................................... aged

about ……… years, of Village/ Town .................................................................................... P.O.
…………..………………P.S ………….……………….………………Dist.………………….………
State .................................. PIN ...............................and certify that, he / she is free from
deafness, defective vision (including color vision) or any other infirmity, mental or physical,likely
to interfere with the efficiency of his / her work and found him / her to possess good health.

Signature of Candidate:

Signature of Medical
Officer:

Name of Medical
Officer:

Registration No.

Dated: Seal