Form V

[See Rule - 8& 52 (8)]

The medical examination shall be conducted by a qualified medical practitioner as per

following proforma:

A. Demographics:

Question Answer Remarks

Date:

Name of the Worker:

Age:

Permanent Address:

Gender:

Total Number of family Members:

Total monthly family Income:

Is the employee under ESI (Employees‘

State Insurance) Scheme? If yes, provide IP Yes/No

Number.

Is the employee under any other health

scheme apart from ESI-Scheme? (If yes, Yes / No

provide the name of the scheme)

B. Occupational History

Question Answer Remarks

Present Designation:

Work Profile:

Duration of service in the present work

profile:

Working Hours per shift:

Night Shift Per Week:

Night Shift per Month:

C. Brief Review of Medical History: Diagnosed previously or currently under treatment or

Currently suffering from

Question Answer (Yes/No) Remarks

Anaemia

Jaundice

Asthma

COPD

History of Any other Lung Disease: (If Yes,

Please Specify)

Vertigo/Dizziness

Diabetes Mellitus

Hypertension

Any Cancer (If Yes, Please Specify the

Cancer)

Chronic Low Back Pain

Chronic Pain in hand or Elbow

Hernia

Hydrocele

Varicose Vein

Haemorrhoids

History of amputation/fracture/dislocation

injury during work (If Yes, please specify)

Dermatitis (If Yes, specify Site)

Hearing Impairment

Visual Impairment

Any Major Illness requiring hospitalization in

last 1 year (If Yes, Name of the Disease)

Occupational Injury in Last 1 year: if yes

Specify the Location of injury and frequency

D. Current Symptoms-Diseases Module

Question Answer (Yes/No) Remarks

Smoking habit

Chewing Tobacco or Pan Masala or Gutkha:

Alcohol Addiction

Dermatosis (Irritant Contact

Dermatitis/Eczema/Chloracne/Allergic

Contact Dermatitis):

Mucosal Irritation of eyes/Nose/Throat with

response to chemical agent or biological

agent:

Symptoms like Respiratory Difficulty/ Chest

Tightness/ Dry Cough at beginning of shift:

Currently suffering from TB:

Jaundice or Hepatitis:

Currently suffering from Low Back Pain

Currently suffering from Pain in hand or

Elbow:

Currently suffering from Visual Problems

Currently suffering from Hearing Problems

Any current injury (amputation/ fracture/

dislocation)

Any current musculoskeletal sprains/ strains

E. Physical Examination

Date of Examination:

Answer (Yes/No) or as

Question Remarks

appropriate

General Skin Condition: (If Any Dermatitis, please

mention its location)

Weight (in Kg):

Height (in Meter)

Temperature (0F):

BP:

Pulse:

SpO2:

Respiratory Rate:

Examination of Breast of female-employee

F. Investigation Report

 Routine Blood Investigation: Attach the photocopy of the report

 Blood Grouping & Rh Typing and HB Electrophoresis Once in a life time

Answer

Parameter Value

(Normal/Increase/Decrease)

Hb%:

Total WBC Count and Differential Count:

Platelet Count:

ESR:

FBS:

PPBS:

HBA1C level

BUN:

Creatinine:

Total Protein

Albumin

Globulin

SGOT

SGPT

Bilirubin

Urine RE

Urine ME

Prostate Specific Antigen (PSA)

G. Standard Chest X Ray (PA) View: attach the photo copy of the report Date :

Parameter Answer (Normal/Abnormal) Value ( if any

importance)

Report

H. Spirometry: attach the photocopy of the report (For mine employee) Date:

Parameter Answer Value

(Normal/Increase/Decrease)

PEFR:

FEV :

1

Observed:

Predicted:

FVC:

Observed:

Predicted:

FEV /FVC:

1

Final Report: Normal / Obstructive Lung Disease/

Restrictive Lung Disease/ Mixed Lung Diseases

I. Audiometry (Pure Tone / BERA): attach the photocopy of the report

(For Mine Employee) Date:

Parameter Value/Result/Interpretation

Visual inspection of Ear for any abnormality like wax

in external ear, infection etc

Right Ear Hearing Threshold:

Left Ear Hearing Threshold:

Final Report preferable based on BERA:

Right Ear:

Left Ear:

J. Eye Examination: attach the photocopy of there port Date:

Parameter Value/Result/Interpretation

Visual inspection of Eye for any abnormality like

corneal opacity/scaring, cataract etc.

Visual Acuity: Right

Visual Acuity: Left

Colour Vision

Field of Vision

Binocularity

Lateral Phoria

Vertical Phoria

Stereoscopic Vision and Depth Perception Testing

Fundus (Retina) examination

K. 12 lead ECG and Echocardiography:

Final Report :

L. MEDICAL FITNESS TESTS FOR PERSONS WORKING AT HEIGHT (as may be applicable):

1. Detailed Medical History and in-Depth General Medical Examination including tests for Vision,

Hearing, Musculoskeletal System, Respiratory System, Cardiovascular Systematic.

As applicable to all employees

2. Special Examination

(a) Cardiovascular

Uncontrolled hypertension or ischemic heart disease will be a contraindication. In the

presence of hypertension and abnormal ECG findings, the employee should be referred

to a Cardiologist for fitness.

(b) Tests for Labyrinthine functions and for sense of position Eye Examination for Bilateral

Nystagmus, Rombergsign. The presence of bilateral nystagmus and a positive Romberg

sign will be an absolute contra-indication.

(c) Neurological examination Evaluate seizure disorders: CT Scan of Brain and E.E.G if

indicated

(d) Assessment of Diabetic Control Status:

(in case of employees suffering from Diabetes Mellitus)

(e) Assessment of Phobia (Acrophobia) and any other Mental Health Disorder like Anxiety

or Depression

(f) Evaluation for Vertigo and Dizziness

For use of Industrial Safety Section:

Walking freely over a horizontal bar at 1 ft. height: PASS / FAIL

Wearing a safety belt and tying the rope knot: PASS/ FAIL

Walking over a horizontal structure at 9 ft. height wearing a belt: PASS/ FAIL

General physique (O.K./NOT O.K): PASS/ FAIL

M. Any other information/examination/biological investigation/test as mutually agreed by

the employer and qualified medical practitioner.