Holcim (Lanka) Limited.

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Medical Examination Report

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Section A

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fiajfhka bj;a lsrsug ;rus nrm;, jrola nj jsfYaIfhka ie<ls,a,g .; hq;=h. This section must be

completed by the candidate ,and handed over to the Medical Officer appointed to examine him.
Candidate are requested to note that any misrepresentation of facts relating to the information
requested below , will be considered & just for dismissal.
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Name Full :

Occupation :

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Section :

PC No :

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Civil Status :

Date of Birth :
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What operations have you had during the past year :

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Are you now in good health :

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Are you temperate in your habits :
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Have you ever suffered from or were you told you had any of the following conditions. Please tick ( ) in

appropriate box. (during the past year)

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Yes
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Heart Ailments
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High Blood Pressure
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Hernia
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Cough
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Pleurisy
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Sugar in Urine
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Arthritis

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No

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Rheumatism
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Epilepsy or Fits
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Prolonged Fever
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Tuberculosis
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Nervous Breakdown
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Asthma
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Kidney Ailments

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Date :

Signature :

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-02SECTION B
To be completed by the Medical Officer
Examining the candidate

1. PHYSICAL RECORDS
Any Defects In
Age

Months
Yrs.
Speech

Height
CM
Weight

Hearing
Kg
AudioMetery

BMI
Chest
Measurement

Inspiration
Feet
Full Inspiration

Abdomen
Measurements

2. CARDIOVASCULAR SYSTEM
Heart
Pulse Rate
Blood Pressure
ECG

3. RESPIRATORY SYSTEM
Nasal Passages and
sinuses
Lungs
X-ray of Chest
Spirometry

4. DIGESTIVE SYSTEM
Tongue
Teeth
Gums
Throat
Liver ,Spleen & Abdominal
Organs
Hemorrhoids

Others

-035. NERVOUS SYSTEM

Mental Functions
Pupils
Knee Jerks
Romberg Signs
Insanity
Any other defects

6. GENITO URINARY SYSTEM

7. LYMPHATIC SYSTEM

8. VISION
Is the applicant colour blind ?
Without glasses

Vision

Color Vision (If Necessary)

9. STOOLS (If Necessary)

10. ANY TRACE OF VENERAL DISEASES

11. URINE ANALYSIS

With glasses

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1. Lipid Profile

2. TSH
3. Fasting Blood Sugar
4. SGPT
5. PSA (Males only)
6. Full Blood Count

7. Serum Creatinine

13. For Females (If Necessary)

1. Paps Smear

2. Other Test

14.
1

Hernia

Varicose Veins

Any observations/recommendations:

Date :

Signature of Medical Officer.