APPENDIX NINE (IV) CONSOLIDATED MEDICAL EXAMINATION RECORD FORM [Vide Rule 48.6]
APPENDIX NINE (IV)
CONSOLIDATED MEDICAL EXAMINATION RECORD
FORM
[Vide Rule 48.6]
Name
of the High School
1. Serial
no. . . . . .
.
2. Standard/division . . . .
3. Name
of the pupil . . . .
4. Guardian’s
remarks . . . .
5. Birth
date . . . . .
.
6. Age
. . . . .
.
7. History
if previous diseases . .
8. Primary
vaccination . . . .
9. Re-vaccination . . . .
10. Physical
education, school . .
11. Physical
education, home . . . .
12. Height
in cms. . . . .
13. Wight
in kgs. . . . .
Stature –
(1)
Short-S.
(2)
Tall-T.
(3)
Normal
Class
14. Health
. . A.
15. B.
16. C.
17. Eyes
of refraction. . . . Right. .
18. Left
. .
19. Diseases . . . . .
.
20. Ears
. . . . . .
21. Nose
. . . . . .
22. Throat . . . . .
.
23. Tonsils . . .
. . .
24. Teeth
. . Carries .
.
25. Dirty
. . .
.
26. Circulator
system . . . .
27. Respiratory
system . . . .
28. Digestive
system . . . .
29. Renal
system . . . .
30. Nervous
system .
. . .
31. Skin
diseases . . . .
32. Joints,
bones and muscles . . . .
33. Lymph
glands .
. . .
34. Genital
system (boys) . . . .
35. Genitory
(girls) .
. . .
36. Special
points . . . .
37. Guardian’s
consent . . . .
Defects Noted
38. Eyes
. . . . . .
39. E.
N. T. . . . . . .
40. Teeth . . . . . .
41. Surgical
. . . . . .
42. Medical . . . . . .
43. Date . . . . . .
44. Remarks . . . . .
.
45. Margin sr. no. . . . . . .
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