(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