APPENDIX NINE (III) FORM OF MEDICAL EXAMINATION [Vide Rule 48.6]- SS CODE

APPENDIX NINE (III)

FORM OF MEDICAL EXAMINATION

[Vide Rule 48.6]

(A) Report of the medical examination taken on

 

                        Name of the school                                                                                         Place

1. Name of the pupil in full (beginning with

Surname in block capitals).

 

2. Birth date                            . .                     . .                     . .

 

3. Guardian’s name     . .                     . .                     . .

 

4. Guardian’s address . .                     . .                     . .

 

5. Guardian’s occupation and annual income                         . .

 

6. Permanent physical deformity, if any                                 . .

 

7. Previous illness, if any        :

Record dates against the disease.

(Note- It may be desirable to obtain this information from the guardian.)

(i) Smallpox                             (v) Disease of eye

(ii) Measles                              (vi) Disease of ear

(iii) Diptheria                           (vii) Rickets

(iv) Tonsils                              (Viii) any other diseases.

 

8. Preventive measure taken [See note above vide 7]

(a) Vaccination date    (d) Triple vaccination date

(b) Revaccination date            (e) any other preventive measure

(c) B.C.G. date

 

9. Operations done, if any: [See note above vide 7]

 

Physical measurements

(To be taken every year, seven/four columns one for each year).

(1) Date                                                           :

(2) Standard and division                               :

(3) Age in completed years                 :

(4) Height in Cms.                                          :

(5) Wight in Kgm.                                           :

(6) Chest expiration                                        :

            Inspiration                                           :

            Difference                                           :

(7) Abdomen in Cms.                         :

(8) Milk, if taken daily, how much     :

 

(B) Medical Examination (Seven/four Columns)

1. General build and constitution       :          

A- Very good, B- Good, C- Poor                   :          

Build Stature  :

2. Illness since the last examination    :          

3. Sight with glasses   . .         R.E.     . .        

                                                            L.E.     . .        

Sight without glasses  . .         R.E.     . .        

                                                            L.E.     . .        

Disease, if any             . .                     . .        

4. Ear-hearing disease . .                     . .        

5. Nose            . .                     . .                     . .        

6. Throat/Tonsils other defects                       . .        

7. Teeth-carries/dirty   . .                     . .

8. Speech                                 . .                     . .

9. Cardiovascular system        . .                     . .

10. Respiratory system            . .                     . .

11. Digestive system   . .                     . .

12. Genits- Urinary system-                . .

       Males- Herina                   . .                     . .

                    Hydrocele           . .                     . .

                    Phimosis  . .                     . .

                    Testes                  . .                     . .        

                   Cleanliness           . .                     . .

       Females- Menstrual history                      . .

13. Skin- Scabies-                                           . .

                 Ringworm              . .                     . .

                 Other diseases        . .                     . .

14. Glands, bones, joints, feet, posture           . .

15. Nervous system     . .                     . .

16. Personal cleanliness- hair nails, etc.

17. Other defects, if any         . .                     . .

18. Remarks and advice          . .                     . .

19. Follow up: Reference to the results

20. Previous suggestions carried out or not

21. Exemption from physical exercise,

If any. If advised, the nature of the

Same.

 

Date:                                                                                                               (Signature of the school doctor)

 

*        Underline a defect in red.

*        Mention to serial nos. of defect against serial no. 17 and the nature of advice.

*        Write the reference to who in column 19 and the result after the follow up is completed. Against column 21 write the nature of exemption, if suggested. If temporary, the period and from what type of exercises.

 

N.B:- The guardian should note the defects pointed out vide serial nos. 1 to 21 of the part (b) above and should write below as to what step he proposes to take remedy the same (i.e. strike out the sentences out of the four alternatives mentioned below which are not wanted retain only one or two sentences which is/are wanted).

 

Date:                                                                                                               (Signature of the Headmaster)

 

1.      We will do the needful for the defects noted above.

2.      The school authorities are requested to do the needful.

3.      We will pay the full/partial cost of the same.

4.      We will not be able to pay any cost for the same.

 

Date:                                                                                                               (Signature of the Guardian)