Medical Checkups
Name :
Mr.
Age / Sex :
Y / Male
Date :
MEDICAL HISTORY
Mental illness
Epilepsy
Chronic Asthma
Diabetes Mellitus
Hypertension
Tuberculosis
Heart Disease
Malaria
Operations
HEAD & NECK
Respiratory system
CVS
Pulse Rate
Bp
ABDOMEN
Liver
Spleen
Others
GENITALS
Hernia
Hydrocele
NIL
Testis
NORMAL
SKIN
NORMAL
No chronic illness
EYE SIGHT
( R )
( L )
Distant Vision
Colour Vision
NERVOUS SYSTEM
Tremors
Jerks
EXTREMITIES
Upper
Lower
WEIGHT
HEIGHT
BLOOD/ URINE
Reports
PFT
X-Ray report
Audiometry
ECG Report