The Human Resources Department Senior Medical Officer
Kindly examine Mr/ Mrs./Miss ..who is being considered for our employment at our Life Spring Hospitals.
Date : Signature
Height Weight : ..
Inspiration Expiration :
BLOOD PRESSURE :
Lying Standing :
Anemia Jaundice Lymphadenopathy Edema
SYSTEM EXAMINATION :
PAST HISTORY : Asthma, Heart Disease , TB, Hepatitis, Chicken pox, Depression,
Major psychiatric disorder, Epilepsy, Drug and alcohol dependence,
Any other etc.
Allergy : Any Medication Latex
PRESENT STATUS ON INVESTIGATIONS :
REMARKS : FIT/ UNFIT/ TEMPORARILY UNFIT.
SIGNATURE OF THE DOCTOR WITH DATE :
NAME OF THE DOCTOR ((in block letters)):
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