Form-IV
(See regulation 16(4) )
Public Health Medical Examination Form
Pupil's Name__________________________________________Married/Unmarried
Address :_____________________________________M/F. Date of Birth_______________
Year of Examination 19 19 19 19
Standard and Division
Age in years and months.
1. History of diseases
operations or accidents
2. P.V. + R.V. + BCG when
3. Diet +Veg
Hostel Non-N.Q. M.T.
4. P.T. +School + Home
5. Height Exp. + Pnsp
Weight Abdominal.
6. Heart + Pulse. P.M.
Physic + Anaemia.
7. Respiratory System
8. Digestion-Appetites-Bowels.
9. Nervous system
10. Renal system
11. G.B. Phymosist :
under Testis
G G M C Y IV
D.D.
12. Eyes Diseases Vision R + L.
13. Ears D + Nose D
14. Throat + Tonsils
15. Teeth caries + Dirty
16. Lymph glands. C.G.
17. Skin diseases.
18. Bones + M + Joints
19. Health class - A+B+C
20. Anything remarkable
21. Special Examination,
When and if taken
22. Teacher's observations.
23. Parent's observations.
24. Doctor's observations.
25. Suggestions for follow up
26. Signature of Medical Practitioner and Date of Examination.
Name of the School :
Follow-up from Health Certificate, at the time of leaving the school.
Eyes. 1 ENT 2 Teeth 3 Surgi. 4 Medi. 5 H/Wt. 6 Age.H.C. 7 G.R. Date8
ist Year : 1. Consultant's Name2. H.S. Findings3. Specialist's Findings.4. Treatment Adv.5. Treatment given + R II nd year: 1. Consultant's Name2. H.S. Findings3. Specialist's Findings.4. Treatment Adv.5. Treatment given + R
Eyes. 1 ENT 2 Teeth 3 Surgi. 4 Medi. 5 H/Wt. 6 Age.H.C. 7 G.R. Date8
3rd Year : 1. Consultant's Name2. H.S. Findings3. Specialist's Findings.4. Treatment Adv.5. Treatment given + R4th year: 1. Consultant's Name2. H.S. Findings3. Specialist's Findings.4. Treatment Adv.5. Treatment given + R5th year: 1. Consultant's Name2. H.S. Findings3. Specialist's Findings.4. Treatment Adv.5. Treatment given + R
Eyes. 1 ENT 2 Teeth 3 Surgi. 4 Medi. 5 H/Wt. 6 Age.H.C. 7 G.R. Date8
6th Year : 1. Consultant's Name2. H.S. Findings3. Specialist's Findings.4. Treatment Adv.5. Treatment given + R7th year: 1. Consultant's Name2. H.S. Findings3. Specialist's Findings.4. Treatment Adv.5. Treatment given + R
|
