Employee Medical Form ( Form O )
Personal Information
CPF No/ Emp Id
Employee Name
Age
Gender
Select
Male
Female
Other
D.O.J
Present Location
PME/IME Date
Identification Mark
Height
Weight
Medical Information
Eyes
Visual Acuity
Select
Normal
Abnormal
Night Blindness
Select
Yes
No
Colour Blindness
Select
Yes
No
Eyes - Others
Ears
Respiration System
Inspiration (cm)
Expiration (cm)
PFT
Circulation System
BP
PULSR
CVS System
S1/S2
OTHERS
Nervous System - CNS
Nervous System - PNS
Abdomen System
Skin
Blood Sugar
CBC
Lipid Profile
Ure.RE
USG
CXR
ECG
2DECHO
DIAGNOSIS
ADVISE
FINAL REMARKS
Select
FIT FOR WORKING IN ANY EMPLOYMENT BELOW GROUNDS/MINES
UNFIT FOR WORKING IN ANY EMPLOYMENT BELOW GROUNDS/MINES
Upload Supporting Documents
Document 1
Document 2
AUTHORITY SIGNATURE
EMPLOYEE SIGNATURE
Submit Form
