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    AME Form

    Uploaded by

    ramesh Itbp
    Kayakarpam

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    AME Form

    Uploaded by

    ramesh Itbp
    3 views2 pages
    Kayakarpam

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

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    Kayakarpam

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    3 views2 pages

    AME Form

    Uploaded by

    ramesh Itbp
    Kayakarpam

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Medical Examination form for GO’s, So’s and Or’s in C.A.P.F.

    1. Regtl. No. 8. Weight


    2. Rank 9. Blood group
    3. Name 10. B.M.I.
    4. Unit/Coy 11. Chest (normal - with expansion)
    (not for ladies)
    5. Age 12. Abdominal Girth
    6. Sex 13. Trans-trochanteric Girth
    7. Height 14. Ratio

    DECLARATION BY THE OFFICIAL TO BE EXAMINED FOR SHAPE CATEGORIZATION


    SL.NO Particulars Please record your answer
    1 Where you examined for any major ailment for hospitalized during last one
    year.
    2 Are you a patient of :-
    a) Hypertension (High Blood Pressure)
    b) Ischemic Heart disease.
    c) Diabetes Mellitus?
    d) Chronic Cough/Bn Asthma / COPD?
    e) Epilepsy (Fits)?
    f) Persistent Headache?
    g) Mental instability?
    3 Have you suffered from Giddiness at any time?
    4 Have you suffered from chest pain /palpitation?
    5 Did you ever suffered from Tuberculosis?
    6 Your (a) Appetite
    (b) Sleep
    7 Smoking habit ( if yes, no of cigarettes per day)
    8 Any accident /injury/major surgery undergone so far?
    9 Any alcohol intake ?
    10 Have you been transferred recently or under orders of transfer? If so your
    a) Previous unit.
    b) New unit
    It is further certified that the above fact stated by me are true to my best knowledge and belief. I have not
    suppressed any fact concerning my health condition ever in past and as if at present.
    Place : Signature_______________
    Date : Name___________________
    Rank__________________
    IRLA/Force No_________
    Unit____________________
    S PHYCHOLOGICAL ASSESSMENT
    Any past history of psychiatric illness, if so detail :
    Any history of break down / outburst or taking wrong decision,
    indecisiveness leading to public reaction or castigation of civil authority
    History of any alcoholic / drug abuse
    History of head injury / infective / metabolic encephalopathy
    Objective psychometric scale if any applied and results there of
    CATEGORIZATION S-1 S-2 S-3 S-4 S-5
    H HEARING
    Normal in both ears
    Moderate defect in one ear
    Partial defect in both ear
    Any other combination
    Auroscopy
    Rennie’s test
    Weber’s test
    Audiometry (if indicated)
    CATEGORIZATION H-1 H-2 H-3 H-4 H-5
    A APPENDAGES
    Upper limb
    Lower limb
    Any loss or infirmity in any joint or part must be indicated in detail
    CATEGORIZATION A-1(U), A-2(U), A-3(U), A-4(U), A-5(U),
    A-1(L), A-2(L), A-3(L), A-4(L), A-5(L)
    P PHYSICAL
    GENERAL EXAMINATION
    Distance covered in 12 minutes run / walk (meters)
    Body built Koilonychias
    BP (mm hg) L N Palpable
    Pulse/min JVP
    Respiration rate Teeth/denture
    Temp (F) Tonsils
    Cyanosis Tongue
    Icterus Throat
    Oedma Thyroid
    Clubbing Spleen
    CARDIO VASCULAR SYSTEM
    Heart sound Murmur if any
    RESPIRATORY SYSTEM
    Chest deformity Percussion
    Breath sounds Advent sounds
    CENTRAL NERVOUS SYSTEM
    Higher functions
    Memory Personality
    Intelligence Orientation (Time, Person, Place)
    Cranial nerves Meningeal signs
    Motor system
    Muscles nutrition Wasting
    Tone Co-ordination
    Abnormal movements Abdominal &
    Cremasteric reflex
    Power Fasciculation
    Planter Gower’s sign
    Cerebellar’s sign Romberg’ sign
    Reflexes Skull & bones
    SLR Finger / Toes

    Abdomen
    General Palpable mass
    Any abnormality Piles / fissure
    Fistula Rectal prolapsed
    Investigation
    Hb % g/dl Urine exam
    Blood Sugar(F) mg/dl ECG
    Blood urea mg/dl Sr. Cholesterol mg/dl
    I agree / do not agree to undergo HIV test.
    Signature of individual
    CATEGORIZATION P-1 P-2 P-3 P-4 P-5
    E EYE SIGHT / VISION

    Distant vision Near vision


    Colour vision Field vision
    IOL Any pathology
    CATEGORATION E-1 E-2 E-3 E-4 E-5

    FINAL CATEGORIZATION S H A P E–

    ADVICE / EMPLOYMENT RESTRICTION(S) IF ANY

    (NAME OF MEDICAL OFFICER)/BOARD MEMBERS


    DESIGNATION/UNIT

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