Medical Fitness Certificate
Candidate’s
photograph, attested
by the Medical
Practioner
(A) Personal information:
1. Candidate’s name (in BLOCK letters): _________________________________________________
2. Father’s /Guardian’s name: ____________________________________________________________
3. Date of birth: ___________________________
4. Present address: _______________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
5. Permanent address: ____________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
(B) History of illness:
1. Past and present illness:
2. Family history:
(C) Physical examination:
1. Height:
2. Physical built:
3. Deformity:
4. Posture and gait:
5. Condition of skin and mucous membrane:
6. Teeth and gum
7. Hearing:
8. Mental alertness:
9. Blood pressure
10. Pulse and respiration
11. Urine test for Albumin and Sugar:
12. Blood test for TC, DC, ESR and Hb%:
13. Vision: Right eye: Left eye:
14. Heart:
15. Lung (X-ray chest):
16. Abdomen (Liver and Spleen)
17. Menstrual History (For female candidates):
(D) “I hereby certify that I have examined Mr./Ms. _______________________________________, a candidate
for JENPAS(UG) training course and I couldn’t discover that he/she has any disease
(communicable or otherwise), constitutional weakness or bodily infirmity, except
_____________________________________. I do not consider this a disqualification for the said
training.
According to the statement of Mr./ Ms. _____________________________________, he/ she is
______________________ year old and by appearance he/ she is about ________________________ year
old”.
In view of the above findings, the candidate is
a) FIT OR
b) Unfit on account of __________________________________________________________________________
OR
c) Temporarily unfit on account of ___________________________________________________
_________________________________________________
Full signature of the candidate with date
_____________________________________________
Place: Signature of the Medical Practitioner
Date: Name:
Degree:
Registration No.
Official seal:
