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CANDIDATE STATEMENT AND DECLARATION

The candidate must make that statement required below prior to his Medical Examination and must sign the declaration appended thereto. His/her attention is specially directed to the warning contained iII the note below:1.
2, 3.

State your name in full (in block letters) State your age and birth plate
a)

Have you ever had small pox intermittent or any other fever, enlargement or sippuration of glands, spitting of blood, asthma, heart disease, lung disease, fainting attacks, rheumatism, appendicitis ?
OR

b)

Any other disease or accident requiring confinement to bed and medical or surgical treatment?

4.
5,

When were vou last vaccinated? Have you or any of your near relations been afilicted with consumption, scrofula, gout, asthma, fits, epilepsy or insanity ?

6.

Have you suffered from any form of nervousness due to over-work or any other case? Furnish the following particulars concerning your family:I

7.
I

of brothers No. of brothers I living & state , death & cause Iivinz their aze & dead, their age at, v & cause of death I state of health I of health I of death
No.
b'

I Father's age if Father's age at

I
I
I I

II
I
I

:2: of sisters Mother's age if Mother's age No. sisters No. of 'at living, their age & living & state dead, their age at, death & of health & cause of death state of health cause of death

L
8. 9. 10. 11.

Have you been examined by a Medical Board before ? If answer to the above is Yes, Please State what service/services you were examined for? Who was the examining authority ? When an where was the Medical Board held? Result of the Medical Board's Examination, if communicated to you or if known.

12.

I declare that all the answers are to the best of my belief, true and correct. Candidate's signature Signed in my presence . Signature of the Chairman of the Board. _ _

Note:-The candidate will be held responsible for the accuracy of the above statement. By wilfully suppressing any information he/she will incur the risk of losing the appointment and, if appointed of forfeiting all c1aimto superannuation allowance of gratuity. Contd. 3/-

:3: Report of the Medical Board on (N arne of candidate) Physical Examination 1. General development Nutrition Height (without shoes) Good Fair Average Weight Poor Obese

Thin

Best VI eight
Temperature Girth of Chest:a) b) 2.
.J.
')

When

Any recent change in weight

(After full inspiration) (After full expiration)

Skin :-

0)
(ii) (iii) (iv) (v) (vi)

Any disease Night blindness Defect in colour vision Field of vision Visual acuity Fundus examination With glasses Streftgth of glasses Cyl. Akis Sph.

I Acuity of vision I
Distant R.E. Vision R.E. Near R.E. Vision R.E. Hypermetrophia (Manifest) RE. L.E. 4. 5. 6. Ears Glands :

Naked Eye

I
Inspection

Hearinz o
Thyroid

Right Ear

Left Ear

Condition of teeth Contd. 4/-

:4:
7. Respiratory System : Does physical examination reveal abnormal in the respiratory organs ? (if yes explain fully) : Circulatory system : (a) Heart : Any organic lesions Rate: Standing anything

8.

after hopping 25 times 2 minutes after hopping (b) 9. Blood pressure : Girth Systolic Tenderness Spleen Fistula : Indications of nervous or mental disabilities Diastolic Hernia Kidneys

Abdomen (a)
(b)

Palpable : Liver Tumors HemorrhoIds

10. 11.

Nervous System

Loco-Motor System: Any abnormality Genitor Urinary System : Any evidence of Hydrocele Varicoccla Urine Analysis (a) Physical appearance (b) Sugar (b) Sp. Gr. (e) Casts (c) Albumin (f) Cells

12.

13.

Report of Screening/X-Ray Examination of Chest Is there anything in the health of the candidate likely to render him unfit for the efficient discharge of his duties in the service for which he is a candidate

14.

15.

(i)

State the Services for which the candidate has been examined

(a)
(b) (c)

LAS & IPS


IPS & Delhi, Himachal Pradesh Police Service Central Service Class I & II Contd. 5/-

:5: (ii) Has he been found qualified in all respects for the efficient and continuous discharge of his/her duties in ? (a) (b) IAS & IFS IPS and Delhi, Himachal Pradesh Police Service (See especially height, chest girth, eye sight colour blindness and locomotive system). Transportation Traffic & Commercial Departments of Indian Railways. (See especially height, chest, eye sight, colour blindness),

(c)

'(iii) (iv)

Other Central Services Class 1111 Is the candidate fit for FIELD SERVICE

16.

Mark of identification

Note: The board should record their findings under one of the following +1~~eD ' "ill v catezories aLv~UliV'::' ,FIT (ii) (iii) L_; 'UNFIT on account of Temporarily tJNFIT on account of

,
------(Signature & Seal)

Chairman/President

Member (Signature & Seal)

Member (Signature & Seal)

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