CONFIDENTIAL
MEDICAL FORM
A.F.M.S.F.2 (Ver 2002)
MEDICAL EXAMINATION REPORT ON ENTRY
MEDICAL EXAMINATION HELD AT - 151 BASE HOSPITAL
1. Name in Full TH RENGKANDO LAMKANG 2. Date of Birth 3. Married or 4. Hours
P. No……………………… Rank………......... 06 MAY 2006 Single Flown
(For service candidates only) NA Sex: M/ F Single …NA…..
5. Service: Army / Navy / Air Force 6. Arm / Corp / Branch / Trade ………………………
7. Permanent Address…………………… 8. Identification Marks
……………………………………………………………….. (a) ……………………………………………………………
……………………………………………………………….. (b) ……………………………………………………………
PERSONAL STATEMENT
9. FAMILY HISTORY
If Alive If Expired
Relation
Age (yrs) Health Cause of Death Died (yrs)
Father NA NA Accident
Mother 38 yrs Good NA NA
Brother/Sister Good NA NA
” ”
” ”
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Any Family Hypertension Heart Disease Diabetes Bleeding Mental Night Blindness
History of Disorders Disease
NIL NIL NIL NIL NIL NIL
10. PERSONAL HISTORY
Have you suffered from any of the following illness/conditions?
Illness (Yes / No) Illness (Yes / No)
Chronic Bronchitis / Asthma No Discharge from ears No
Pleurisy / Tuberculosis No Any other Ear Disease No
Rheumatism / Frequent Sore Throats No Frequent Cough & Cold / Sinusitis No
Chronic Indigestion No Nervous Breakdown / Mental Illness No
Kidney / Bladder trouble No Fits / Fainting Attacks No
STD No Severe Head Injury No
Jaundice No (For Female candidates only) No
Air, Sea, Car, Train, sickness No Breast Disease / Discharge No
Trachoma No Amenorrhea / Dysmenorrhea No
Night Blindness No Menorrhagia No
Laser Treatment / Surgery for Eye No Pregnancy No
Any other Eye disease No Abortion No
Have your ever been rejected as medically unfit for any branch of the Armed Forces (Y/N)
Have your ever been discharged as medically unfit for any branch of the Armed Forces (Y/N)
Have you ever been admitted in hospital for any illness, operation or injury?
(Y/N)
If so, state the nature of the damage and duration of stay in hospital
Any other information you can give
NIL
about your health
I hereby declare that I have answered as fully as possible all the questions about my family and personal health
and that the information given is true to the best of my knowledge.
Ect – Hi blindness
– Corrective eye surgeries
Signature of Medical Officer…………………………….. Signature of Candidate……………………………..
Date …………………………….. Date ……………………………..
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EXAMINATION
MEDICINE
11. (a) Height without shoes (b) Weight (actual) Kg (c) Leg Length (for pilots
only) cms
cms (acceptable) Kg
(d) Urine Examination Appearance Albumin Sugar Sp. Gravity
(e) Blood Examination (i) Hb gm %
(ii) Any other inv carried out
(f) Physique
(g) Skin
(h) Abdomen (Liver & Spleen)
(i) Cardio Vascular System (Heart Size, Sounds, Rhythm, Arterial Walls, Pulse Rate and BP)
(j) Respiratory System (including X-Ray examination when Chest measurements
applicable)
Full expansion cms
Range of expansion cms
(k) Central Nervous System Self Balancing
R
L
(l) Speech, Mental capacity & Emotional Stability
(m) Endocrine Conditions
(n) Any other abnormalities or conditions affecting physical capacity not already noted
Remarks
Date: Signature of Medical Specialist
SURGERY
12. (a) Upper Limbs (Fingers, hand, wrists, elbows, shoulder, girdles, cervical and dorsal vertebrae)
(b) Lower Limbs (Hallux valgus rigidus, flat feet, joints, pelvis & Gait)
(c) Lumbar and sacral vertebrae, coccyx and varicose veins
(d) Genito-urinary and perineum (Hydrocele, varicoccle, undescended testes and hemorrhoids)
(e) Hernia & Muscle
(f) Breast
Remarks
Date: Signature of Medical Specialist
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EYE
13. (a) Distant Vision R L (b) Near Vision R L (c) CP
Without Glasses Without Glasses
With Glasses With Glasses
(c) Any evidence of Trachoma / its complications or any other disease.
(d) Binocular Vision & Grade
SPECIAL EXAMINATION WHEN APPLICABLE
Manifest Hypermetropia, Myopia R & L Cover Test
Diaphragm Test (PD Moddox Wing Test Fund & Media
Fields Night Visual Capacity
C cms R cms
Convergence Accommodation
SC cms L cms
Remarks
Date Signature of Medical Specialist
EAR, NOSE & THROAT
14. (a) Ear
(i) Hearing R L Both
FW cms cms cms
CV cms cms cms
(ii) External Ear R L
(Wax)
(iii) Middle Ear
(Tympanic Membrane &
Eustachian Tube)
(iv) Inner Ear
(Cochlea & Vestibular
Apparatus)
(v) Audiometry Record (Special exam when applicable)
(b) Nose
(c) Throat
Remarks
Date Signature of ENT Specialist
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DENTAL
15. (a) Total No. of Teeth Missing/Unsaveable Teeth
(c) Total Defective Teeth U R 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 U L
(d) Total Dental Points L R 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 L L
(b) Conditions of Gums Missing teeth to be indicated by Horizontal line (--) and
Unsaveable teeth by a cross (x) through the appropriate number
Remarks
Date Signature of Dental Specialist
GYNAECOLOGY – NOT APPLICABLE
16. (a) Menstrual History (b) LMP
(c) No. of pregnancies (d) No. of Abortions
(e) No. of children (f) Date of last confinement
(g) Vaginal Discharge (h) Prolapse
(i) USG Abdomen
Remarks
Date Signature of Gynaecologist
FINDINGS OF MEDICAL BOARD / EXAMINATION
Place
Date : Member Member Signature of President
FINDINGS OF THE SUBSEQUENT MEDICAL BOARD / EXAMINATION
Place
Date : Member Member Signature of President
APPROVING AUTHORITY
(where applicable)
Place Signature
Date : Rank & Designation
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