Form V

(See Rule -6)

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 Yes/No

(Employees‘ State

Insurance) Scheme? If yes,

provide IP Number

Is the employee under any other Yes/No

health scheme apart

from ESI-Scheme? (If yes,

provide the name of the

scheme)

B. Occupational

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 Remarks

Anaemia

Jaundice

Asthma

COPD

History of Any other Lung Disease: (If Yes, Please

Specify)

Question Answer Remarks

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 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/ ChestTightness/ 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:

Question Answer Remarks

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 lifetime

Parameter Answer 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 photocopy of the report

Date:

Parameter Answer (Normal/Abnormal) Value ( if any importance)

Report

Report

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

Date:

Parameter Answer Value

(Normal/Increase/Decrease)

Report

Observed:

Predicted:

FVC:

Observed:

Predicted:

FEV1/FVC:

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 Eye 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 the report

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

System etc.

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, Romberg sign.

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

d) 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.