FORM 21
[Prescribed under Rule (19)]
Health Register
(In respect of persons employed in occupations declared to be dangerous operations under Section 87)
(a) Shri From To
Name of Certifying Surgeon (b) Shri From To
(c) Shri From To
Serial Works Name of Sex Age (last Date of Reason for Reason for Nature of job
No. No. Worker birth day) employment on leaving leaving or occupation
present work transfer or transfer or
discharge discharge
(1) (2) (3) (4) (5) (6) (7) (8) (9)
Raw Date of Medical If suspended from Recertified fit to resume If certificate of Signature
material or Examination by work, state period of duty on (with signature unfitness of with date
by product Certifying Surgeon and suspension with of certifying surgeon) suspension issued of
handled result of medical detailed reasons to work certifying
Examination surgeon
(10) (11) (12) (13) (14) (15)
(a) (b) (c)
(d) (e) (f)
(g) (h) (i)
Note.- (i) Column (8) - Detailed summary of reasons for transfer of discharge should be stated.
(ii) Column (11) - Should be expressed as fit/unfit/suspended.
Annexure
PRE-EMPLOYMENT & PERIODIC MEDICAL EXAMINATION
(1) GENERAL EXAMINATION:
HEIGHT: _____________CM, WEIGHT: ______________KG, BMI__________________
CHEST: INSPIRATION _______CM, EXPIRATION: _______CM.
BUILT – AVERAGE/ STRONG/ POOR
THROAT __________, TONGUE __________, TONSILS _______________
TEETH________, GUMS _________, THYROID______________________
LYMPH NODES ______________________________________________
ADDITIONAL FINDINGS _______________________________________
(2) CARDIO-VASCULAR SYSTEM:
PULSE: ___ / MIN. REGULAR/ IRREGULAR PERIPHERAL PULSE – FELT/ NOT FELT
B.P. ___________ mm of Hg.
HEART SOUND: _____________________________________________
MURMUR, IF ANY: ____________________________________________
ADDITIONAL FINDING (S), IF ANY-_______________________________
(3) RESPIRATORY SYSTEM:
SHAPE OF CHEST: __________________________________________
CHEST MOVEMENTS: _______________________________________
TRACHEA: _________________________________________________
BREATH SOUNDS: ___________________________________________
(4) GASTRO-INTESTINAL SYSTEM:
LIVER: ____________________ SPLEEN: ______________________
ANY ABDOMINAL LUMPS: ________________________________________
(5) EXAMINATION OF EYES:
EXTERNAL EXAM. _______________ SQUINT: _________________
NYSTAGMUS: ____________________________________________
COLOUR VISION – NORMAL/ DEFECTIVE
FUNDUS (L) (R)
INDIVIDUAL COLOUR IDENTIFICATION – NORMAL/ DEFECTIVE
DISTANT VISION (WITHOUT GLASSES)
RIGHT ____________________ LEFT _________________________
(WITH GLASSES) RIGHT ______________ LEFT ________________
NEAR VISION (WITHOUT GLASSES)
RIGHT ______________________ LEFT _______________________
(WITH GLASSES) RIGHT _____________ LEFT ______________
NIGHT BLINDNESS: (NYCTALOPIA): _____________________________
(6) EXAMINATION OF EAR, NOSE &THROAT:
EXTERNAL EXAM: ___________________________________________
(7) GENITO URINARY SYSTEM:
HERNIA: ______________ HYDROCELE/ VARICOCELE _____________
CRYPTORCHIDISM ______________ PHIMOSIS _________________
VARICOSE VEINS _____________SIGNS OF STD _________________
OTHER EXAMINATION FOR FEMALES:
MENSTRUAL HISTORY OBSTETRIC HISTROY
MENARCHE AT ______ Yrs. GRAVIDA __________ PARA__________
LMP - ______________________________________________________
MENSTRUAL IRREGULARITY, IF ANY
INVESTIGATIONS
(8) LAB INVESTIGATIONS:
URINE: ALBUMIN _______________________, SUGAR _____________________
MICROSCOPY ___________________, STOOL: ____________________
HAEMOGRAM
Blood Group:_____ Rh factor:_____ Hb _____ TLC _____ RBC _________
DLC – P L E M B Platelets Count___________________
LIPID PROFILE
Serum cholesterol:, S/Triglycerides
HDL, LDL
HEPATIC PROFILE
SGPT: SGOT:
Alkaline Phosphatase:
RENAL PROFILE
Blood Urea:, S/Creatinine:
METABOLIC
Blood Sugar – F:, Blood Sugar – PP:, S/uric acid: ________________________________________
(9) OTHER INVESTIGATIONS:
X-Ray Chest (In normal persons once in three years, ______________________________________
in case of any abnormality x-ray can be done at shorter intervals)
ECG (In case of any abnormality further tests should be carried out) __________________________
Ultra Sound Whole abdomen (In normal persons once in three years in case of any abnormality can
be done at shorter intervals) ________________________________________________
Others:_____________________________________________________________
(10) PULMONARY FUNCTION TEST
FVC FEV 1 FEV 1 / FVC
Predicted
Measured
% of Predicted
Remarks:
(11) Audiometry examination - PTA of both ears at frequency of 125, 250, 500, 1000, 2000, 4000, 8000
Cycles per second
(12) Medical examination of canteen staff
a- Blood examination for venereal disease and routine blood examination.
b- Stool and urine examination for worm infection
c- Screening for skin diseases (scabies and others)
d- X-ray and other tests for T.B.
(13) Details of Other specific medical examination carried out as mentioned in the respective
schedules of rule 107 of C.G. factories rules 1962 -
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Signature (with date) of
Factory Medical Officer
Signature (with date) of
certifying surgeon
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