Medical Certificate

This medical certificate is used by people being employed by institutions that require health certificate like hotels and food related businesses.

Note: If it is a government entity use GP69 medical form. You can download it here.

MEDICAL CERTIFICATE

This form should be completed by a Government Medical Officer or his assistant in a Government hospital. The completed form must be submitted with the admission letter during admission.

Name………………………………………………………………………………...

Age…………………………………………………………………………………..

TO BE COMPLETED BY THE MEDICAL OFFICER ONLY

1. Is there any noticeable disability?.................................................................
2. Eyes? ………………………………………………………………………
3. Hands? …………………………………………………………………….
4. Feet? ………………………………………………………………………
5. Chest?...........................................................................................................
6. Breathing? …………………………………………………………………
7. Hearing? ……………………………………………………………………
8. Blood Pressure?............................................................................................
9. Heart? ……………………………………………………………………..
10. Rheumatism ………………………………………………………………
11. Communicable disease……………………………………………………
12. Has the person ever been treated for severe illness?...................................
13. If yes, describe……………………………………………………………
14. Has the person ever been operated on?......................................................
15. Weight ……………………………………………………………………
16. Height…………………………………………………………………….
17. Blood sugar level ………………………………………………………..
18. Urine …………………………………………………………………….
19. Stool …………………………………………………………………….
20. Any other finding………………………………………………………..

Name of Medical Officer…………………………………………………………………...

Signed……………………………………………………………………………………….. 

Official Stamp………………………………………………………………………………

Date …………………………………………………………………………………………