Form 7

{see sub-rule (2) of rule 13 and sub-rule (5) of Rule 74 and sub-rule (3) of Rule 125 and sub-

rule (1) (c), of Rule 139 and sub-rule (1), (2) of Rule 167}

Health Register

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

A. Demographics:

Question Answer Remarks

Date

Name of worker

Age

Permanent address

Gender

Total Number of family Members

Total monthly family Income

Is the employee under ESI (Employees‘ State Yes/No

Insurance) Scheme? If yes, provide IP Number

Is the employee under any other health scheme Yes/No

apart from ESI-Scheme? (If yes, 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

Anemia

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

Question Answer (yes/no) Remarks

Date of examination

General Skin Condition: (If Any Dermatitis,

please mention its location)

Weight (in Kg)

Height (in Meter)

0

Temperature ( F)

BP

Pulse

SPO2

Respiratory Rate

Examination of Breast of female-employee

F. Investigation report:

(a) Routine blood investigation (attach the photocopy of the report)

(b) Blood grouping and Rh Typing and Hb Electrophoresis (once in a life time)

Parameter Answer (Normal/ Increase/ Value

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 copy of the report):

Parameter Answer (Normal/ Value (if any

Abnormal) importance)

Date

Report

H. Eye examination: (attach the photocopy of the report)

Parameter value/ result/ interpretation

Date

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

I. ECG and Echocardiography:

J. Final report:

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

L. 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)

M. 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

f) Evaluation for Vertigo and Dizziness

N. For use of Industrial Safety Section:

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

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

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

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

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

employer and qualified medical practitioner.

Signature, seal and registration no. of qualified

medical practitioner / factory medical officer

Signature & seal

Medical Officer

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