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Form11 Medical Examination

This document contains a certificate of medical examination form with the following information: 1. The form includes identification details of the person being examined such as name, father's name, sex, residence, date of birth, and physical fitness status. 2. The examining medical officer certifies that they have personally examined the individual and their age, as well as whether they are fit for certain types of employment. 3. The second page provides details of the medical examination including vital signs, vision, systemic examination of different body systems, immunization details, and remarks or treatment suggestions.

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Shanur Rahman
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10K views3 pages

Form11 Medical Examination

This document contains a certificate of medical examination form with the following information: 1. The form includes identification details of the person being examined such as name, father's name, sex, residence, date of birth, and physical fitness status. 2. The examining medical officer certifies that they have personally examined the individual and their age, as well as whether they are fit for certain types of employment. 3. The second page provides details of the medical examination including vital signs, vision, systemic examination of different body systems, immunization details, and remarks or treatment suggestions.

Uploaded by

Shanur Rahman
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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FORM- XI.

[See rule 223(c)]


Certificate of Medical Examination

1. Certificate Serial No…………………


Date…………………….
Date …………………………
2. Name …………………………………………………………………………………
Identification marks: 1. ………………………………………………
2. ………………………………………………
3. Fathers name …………………………………..
4. Sex ………………………………………………...
5. Residence ……………………………Son/ Daughter/ Wife of Shri …………………….
………………………………………………………………………………………………
6. Date of birth, if available ...………………………………………………………………..
Certificate age ……………………………………………………………………………
7. Physical fitness……………………………………………………………………………..
I hereby certify that I have personally examined (name)------------------------------------
Son/daughter/Wife of………………………………………. Residing at
……………………………………………… who is desirous of being employed in building
and construction work and that his/ her age as nearly as can be ascertained from my
examination ………… Years and that he/ she is fit for employment in …… as an adult/
adolescent.
8. Reason for
1. Refusal of certificate
…………………………………………………………………………………

2. Certificate being revoked.

………………………………………………………………………………..
Details Medical Examination

Name –

Age – Height Weight Temp.

Check Points :-
Habits - Tobacco chewing / Alcohol consumption/ Smoking.
Height Phobia-------- Yes/No
Allergic to medicine/reaction/other-
Occupation H/o-
Personal health H/o-
Suffering from any major illness/diseases in past-

General Examination:
Pulse - bpm

Blood pressure - mm/Hg

Vision - Normal
Corrected with glasses
Require refractory correction for near vision/distance Vision

Systemic Examination:
Resp.-
CVC. -
Abd. -
CNC-
Musculoskeletal System-
Any other finding-
Immunization Details;
Inj. T.T.-
Remark-Treatment/Suggestion-

Stamp & Sign of Medical officer Sign/ Left Thumb Impression of Worker

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