CONFIDENTIAL A.F.M.S.
F 2 (Ver 2002)
MEDICAL EXAMINATION REPORT ON ENTRY
SAINIK SCHOOL GOPALGANJ – ACADEMIC YEAR ________________
(MEDICAL EXAMINATION HELD AT SADAR HOSPITAL, GOPALGANJ ON_________________)
Roll No……………………… Category …………………………Sub Category…………………..
1. Name in Full………………………………. …………………………………………………..
Recent
2. Date of Birth …………………..…………… 3. Single 4. Sex : M / F photograph of
5. Permanent Address ………………………. 6. Identification Marks the candidate
to be pasted
……………………………………………. (a)…………………………………………….……
here and then
……………………………………………. (b)…………………………………………………. duly attested.
PERSONAL STATEMENT
7. FAMILY HISTORY
Relation If Alive If Expired
Age (yrs) Health Cause of Death Died (yrs)
Father
Mother
Brother/Sister
“ “
“ “
Any Family Hypertension Heart Disease Diabetes Bleeding Mental Disease Night
History of Disorders Blindness
8. PERSONAL HISTORY
Have you suffered from any of the following illnesses / conditions?
Illness (Yes / No) Illness (Yes / No)
Chronic Bronchitis / Asthma Discharge from ears
Pleurisy / Tuberculosis Any other Ear Disease
Rheumatism / Frequent Sore Frequent Cough & Cold / Sinusitis
Throats
Chronic Indigestion Nervous Breakdown / Mental illness
Kidney / Bladder trouble Fits / Fainting Attacks
STD Severe Head Injury
Jaundice (For Female candidates only)
Air, Sea, Car, Train sickness Breast Disease / Discharge
Trachoma Amenorrhoea / Dysmenorrhoea
Night Blindness Menorrhagia
Laser treatment / Surgery for Pregnancy
Eye
Any other Eye disease Abortion
Have you ever been rejected as medically unfit for any branch of the Armed Forces (Y/N)
Have you ever been discharged as medically unfit from any branch of the Armed Forces (Y/N)
Have you ever been admitted in hospital for any illness, operation or injury?
(Y/N)
If so, state the nature of the disease and duration of stay in hospital.
Any other information you
can give about your health?
I hereby declare that I have answered as fully as possible all the questions about my family and personal health and that
the information given is true to the best of my knowledge.
Signature of Medical Officer……………………………. Signature of Candidate……………………………………
Date ………………… Date………………………….
CONFIDENTIAL
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CONFIDENTIAL
EXAMINATION
MEDICINE
9. (a) Height without shoes (b) Weight (actual) Kg (c ) Leg Length (for Pilots only)
cms (acceptable) Kg
(d) Urine Appearance Albumin Sugar Sp. Gravity
Examination
(e) Blood Examination
(i) Hb gm %
(ii) Any other investigation carried out
(f) Physique
(g) Skin
(h) Abdomen (Liver & Spleen)
(i) Cardio Vascular System (Heart Size, Sounds, Rhythm, Arterial Walls, Pulse Rate and BP_
(j) Respiratory System (including X-ray examination when applicable) Chest measurements
Full expiration cms
Range of expansion cms
(k) Central Nervous System Self Balancing
R
L
(l) Speech, Mental capacity & Emotional stability
(m) Endocrine conditions
(n) Any other abnormalities or conditions affecting physical capacity not already noted
Remarks
Date Signature of Medical Specialist
SURGERY
10. (a) Upper Limbs (Fingers, hand, wrists, elbows, shoulder girdles, cervical and dorsal vertebrac
(b) Lower Limbs (Hallux valgus rigidus, flat feet, joints, pelvis) & Gait.
(c) Lumbar and sacral vertebrae, coccyx and varicose vains
(d) Genito-urinary and perineum (Hydrocele, varicocele, undescended testes and haemorrhoids)
(e) Hernia & Muscle
(f) Breast
Remarks
Date Signature of Surgical Specialist
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EYE
11 (a) Distant Vision R L (b) Near Vision R L (c ) CP
Without Glasses Without Glasses
With Glasses With Glasses
(c ) Any evidence of Trachoma / its complications or any other disease
(d) Binocular Vision & Grade
SPEACIAL EXAMINATION WHEN APPLICABLE
Manifest Hyperrmetropia, Myopia R&L Cover Test
Diaphragm Test (PO Moddox wing Test) Fundi & Media
Fields Night Visual Capacity
C cms R
Convergence Accommodation
SC cms L
Remarks
Date Signature of Eye Specialist
EAR NOSE & THROAT
12. (a) Ear
(i) Hearing R L Both
CV cms cms cms
FW cms cms cms
(ii) External Ear R L
(WAX)
(iii) Middle Ear
(Tympanic Membrane &
Eustachian Tube)
(iv) Inner Ear (Cochlea &
vestibular Apparatus)
(v) Audiometry Record (Special exam when applicable)
(b) Nose
(c) Throat
Remarks
Date Signature of ENT Specialist
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DENTAL
13. (a) Total Nos of Teeth Missing / Unsaveable Teeth
(c) Total Nos of Defective teeth U.R 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 U.L.
(d) Total Nos of Dental Points L.R 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 L.L.
(e) Condition of Gums Missing teeth to be indicated by Horizontal line (--) and
Unsaveble teeth by a cross (x) through the appropriate number.
Remakrs
Date Signature of Dental Officer
GYNAECOLOGY
14. (a) Menstrual History (b) L.M.P
(b) Nos of pregnancies (d) Nos of Abortions
(e) Nos of Children (f) Date of last confinement
(g) Vaginal Discharge (h) Prolapse
(i) USG Abdomen
Remakrs
Date Signature of Gynaecologist
FINDINGS OF MEDICAL BOARD EXAMINATION
Place
Date Member Signature of President
FINDINGS OF THE SUBSEQUENT MEDICAL BOARD EXAMINATION
Place
Date Member Signature of President
APPROVING AUTHORITY
(where applicable)
Place Signature
Date Designation
CONFIDENTIAL
