Form IV

(See rule-6)

Proforma for medical examination to be conducted by a qualified medical practitioner

A. Demographics:

1. Question Answer Remarks

2. Date:

3. Name of the Worker:

4. Age:

5. Permanent Address:

6. Gender:

7. Total Number of family Members:

8. Total monthly family Income:

9. Is the employee covered under Employees‘ State Insurance Scheme?

(If yes, provide IP Number). Yes/No

10. Is the employee under any other health scheme apart from ESI-Scheme? (If yes, provide the name of

the scheme) Yes / No

B. Occupational History

Question Answer Remarks

1. Present designation of the employee:

2. Work Profile:

3. Duration of service in the present work profile:

4. Working Hours per shift:

5. Night shift per week:

6. Night shift per month:

C. Brief Review of Medical History: Diagnosed previously or currently or currently suffering from:

Question Answer (Yes/No) Remarks

1. Anemia

2. Jaundice

3. Asthma

4. COPD

5. History of any Lung Disease: (If Yes, Please Specify)

6. Vertigo/Dizziness Diabetes Mellitus Hyper tension Any type of Cancer (If Yes, Please Specify the type

of Cancer)

7. Chronic Low Back Pain

8. Chronic pain in hand or elbow

9. Hernia

10. Hydrocele

11. Varicose Vein

12. Haemorrhoids

13. Amputation/fracture/dislocation injury during work (If yes, please specify)

14. Dermatitis (If Yes, specify Site)

15. Hearing impairment

16. Visual impairment

17. Any Major illness requiring hospitalization in last 1 year (If Yes, Name of the Disease)

18. 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

1. Smoking habit

2. Chewing Tobacco or

3. Pan Masala or Gutkha:

4. Alcohol Addiction

5. Dermatosis

(Irritant Contact Dermatitis/Eczema/ Chloracne/Allergic Contact Dermatitis):

6. Mucosal Irritation of eyes/Nose/Throat with response to chemical agent or biological agent:

7. Symptoms like Respiratory Difficulty/ Chest Tightness/ Dry Cough at beginning of shift:

TB:

1. Jaundice or Hepatitis:

2. Low back pain Pain in hand or elbow:

3. Suffering from visual problems suffering from hearing problems

4. Any injury (amputation/ fracture/ dislocation)

5. Any musculoskeletal sprains/ strains

E. Physical Examination

Date of Examination:

Question Answer (Yes/No) or as appropriate Remarks

1. General skin condition:

(If any dermatitis, please mention its location)

2. Weight (in Kg):

3. Height (in meters)

4. Temperature (in o c):

5. BP:

6. Pulse:

7. SpO2:

8. Respiratory Rate:

9. wherever examination of breast of female-employee conducted.

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 (Normal/Increase/Decrease) Value

1. Hb%:

2. Total WBC Count and Differential Count:

3. Platelet Count:

4. ESR:

5. FBS:

6. PPBS:

7. HBA1C level

8. BUN:

9. Creatinine:

10. Total Protein

11. Albumin

12. Globulin

13. SGOT

14. SGPT

1. Bilirubin

2. Urine RE

3. Urine ME

4. 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 employees in Mines)

Date:

Parameter Answer (Normal/Increase/Decrease) Value

1. PEFR:

2. FEV1:

3. Observed:

4. Predicted:

5. FVC:

6. Observed:

7. Predicted:

8. FEV1/FVC:

9. Final Report:

Normal / Obstructive Lung Disease/

Restrictive Lung Disease/

Mixed Lung Diseases

I. Audiometry (Pure Tone / BERA): attach the photocopy of the report (For Employees in Mines)

Date:

Parameter Value/Result/Interpretation

Visual inspection of ear for any abnormality

like wax in external ear, infection etc.

1. Right Ear Hearing Threshold:

2. Left Ear Hearing Threshold:

3. Final Report preferable based on BERA:

4. Right Ear:

5. 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.

a. Visual Acuity: Right

b. Visual Acuity: Left

1. Colour Vision

2. Field of Vision

3. Binocularity

4. Lateral Phoria

5. Vertical Phoria Stereoscopic Vision and Depth Perception

6. Testing

7. Fundus (Retina) examination

K. 12 lead ECG and Echocardiography:

Final Report:

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

a. 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.

b. Special Examination

i. Cardiovascular Uncontrolled hypertension or ischemic heart disease will be a contra-

indication. In the presence of hypertension and abnormal ECG findings, the employee

should be referred to a Cardiologist for fitness.

ii. 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 contraindication.

iii. 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:

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

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

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

d) 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