Medical Checkup Format

Corporate medical checkup report Routine/ pre-employment   Name of patient:

Name of Firm:

Age:

I.D. No:

Sex:

Date:

For PRE- EMPLOYMENT CHECKUP REF. FROM M/S. M/SMAHINDRA HOLIDAYS AND RESORTS LTD. 1. CHIEF COMPLAINT COMPLAINTS S AND AND HISTORY HISTORY OF PRESEN PRESENT T ILLNESS ILLNESS::

2. PAST AST HI HISTOR STORY: Y:

3. PERSON PERSONAL AL HISTOR HISTORY: Y: SMOKIN SMOKING:G:PHYSICAL ACTIVITY: -

ALCOHO ALCOHOL:L:DRUG ALLERGY:-

4. FAMI FAMILY LY HIST HISTOR ORY: Y: 5. PHYSI PHYSICAL CAL EXAMIN EXAMINATI ATION: ON: Height Height::

Weight Weight::

IDENTIFICATION MARKS GENERAL: Normal Heart: Pulse Lungs: Abdomen:  Nervous System: Genito Urinary: Other Relevant Findings (Including ENT, eyes, Dental)

B.P

Heart sound

Murmur 

Investigations: Routine Blood Count: HGB: PCV: Blood Sugar:

TC: DC:

ESR:

Random:

Blood Group & Rh Factor:

Other tests:

Platelet count

:

Urine analysis: Albumin:

Sugar:

ECG: X-ray Chest:

IMPRESSION RECOMMENDATION The Physical examination and the routine investigation under M/s. MAHINDRA HOLIDAYS AND RESORTS LTD – PEC package are within normal limits:

OPINION REGARDING FITNESS:

Physician’s signature