CONFIDENTIAL

A.F.M.S.-3B (Yer-2003)
ANNUAL MEDICAL EXAMINATION

MEDICAL EXAMINATION HELD AT: MH NASIRABAD (RAJ) AUTHORITY: AO/09/2011/DGMS

PERSONAL DATA
1. Number 2. Rank 3. Name 4. Unit/Ship

R-05568H SK Sharma MH Nasirabad

5. Service 6. Arm/Corps 7. Date of Birth 8. Age 43 Yrs

(Army/Navy/Air Force) Branch/Trade Sex (M/F)
Army 1960 55 Yrs 11 Months

9. Type of Commission 10. Date of Commission 11. Total Service: Yrs

PC/SSC Applicabl 29 Yrs 03 Months

12. Past Medical History 13. Present Medical Category

APE-
1 SHAPE-1 Signature of the officer
Date:

14. Last AME carried out at

EXAMINATION
15 (a) Total No of Teeth Missing/Unsaveable Teeth
(b) Total No of Defective Teeth U.R. 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 U.
L.
(c) Total No of Dental Points L.R. 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
L. L.
(d) Condition of Gums Missing teeth to be indicated By Horizontal (-)
and
Unsaveable teeth by a cross (x) through the
appropriate number.
Remarks

Date:
16. Investigations

Blood: Hb…………gm% TLC…….mm3 DLC P…..L……M………E…..B……ESR……..mm full in hour

Urine: RE…… ME……. Sp Gravity…………..
………….Albumin…………..Sugar…………….

Blood Sugar: Fasting…………mg/dl 2hrs Post Prandial………………mg/dl

Lipid Profile: Cholestrol……….mg/dl Triglycerides…………….mg/dl

HDL………mg/dl VLDI…..mg/dl LDL………..mg/dl
X-Ray Chest PA Nos……………………..dated………….Report NAD/

ECG No………………….dated…………. Report………………………..

17 (a) Physical Capicity

(i) Height…………….cm (ii) Weight Actual………..kg (iii) Ideal Wt……kg (iv) Over Wt……….%

(v) Waist………cm (vi) Chest Full Expiration…….cm (vii) Range of Expansion………..cm

-----------------------------------------------------------------------------------------------------------------------------------------------------
(b) Cardio Vascular System
(i) Pulse……./m (ii) BP…………..mm/Hg (iii) Peripheral Pulsations NAD/

(iv) Heart Size NAD/ (v) Sounds NAD/ (vi) Rhythm NAD/

(c) Respiratory System

(d) Gastro Intestinal System

(i) Liver Papable (Y/N)………..cm (ii) Spleen Plapable (Y/N)…………..cm

(e) Central Nervous System

(i) Higher Mental Functions NAD/………. (ii) Speech NAD/………. (iii) Reflexes
NAD/…….

(iv) Tremors Nil/Fine/Coarse…………. (v) Self Balancing Test Fairly Steady/Unsteady

-----------------------------------------------------------------------------------------------------------------------------------------------------
Note- Delete what is not applicable, In case any abnormality is detected. Delete ‘NAD’ and enter findines

CONFIDENTIAL
 CONFIDENTIAL

18 (a) Locomotor System (b) Spine NAD/

(c) Hernia NAD/ (d) Hydrocoele NAD/
(e) Hemorrhoids NAD/ (f) Breast

19 (a) Distant Vision R L (b) Near Vision R L (b)

Without Glasses Without Glasses
With Glasses With Glasses

20 (i) Hearing R L Both (c) Authority

Record
FW Cms Cms Cms
FW Cms Cms Cms
(b) Tympanic Membrane Y/N Y/N
Infact
(c) Mobility (valsalva)
(d) Nose, Throat & NAD/
Sinuses

21. Gynecological Exam

(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 NAD/ (h) Prolapse NAD/
(j) USG Abdomen

22. Immunization status (give details)

FINAL OBSERVATIONS & MEDICAL CATEGORY

(Signature of Authorized Medical Attendant

Medical Specialist)

-----------------------------------------------------------------------------------------------------------------------------------------------------
APPROVING/PERUSING AUTHORITY
(Where applicable)

Signature
Rank & Designation
-----------------------------------------------------------------------------------------------------------------------------------------------------

CONFIDENTIAL
 CONFIDENTIAL
A.F.M.S.-3B (Yer-2003)
ANNUAL MEDICAL EXAMINATION

MEDICAL EXAMINATION HELD AT: MH NASIRABAD (RAJ) AUTHORITY: AO/09/2011/DGMS

PERSONAL DATA
1. Number 2. Rank 3. Name 4. Unit/Ship

5. Service 6. Arm/Corps 7. Date of Birth 8. Age

(Army/Navy/Air Force) Branch/Trade

9. Type of Commission 10. Date of Commission 11. Total Service:

PC/SSC Applicable

12. Past Medical History 13. Present Medical Category

Signature of the officer

Date:

14. Last AME carried out at

EXAMINATION
15 (a) Total No of Teeth Missing/Unsaveable Teeth
(b) Total No of Defective Teeth U.R. 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 U.
L.
(c) Total No of Dental Points L.R. 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
L. L.
(d) Condition of Gums Missing teeth to be indicated By Horizontal (-)
and
Unsaveable teeth by a cross (x) through the
appropriate number.
Remarks

Date:
16. Investigations

Blood: Hb…………gm% TLC…….mm3 DLC P…..L……M………E…..B……ESR……..mm full in hour

Urine: RE…… ME……. Sp Gravity…………..
………….Albumin…………..Sugar…………….

Blood Sugar: Fasting…………mg/dl 2hrs Post Prandial………………mg/dl

Lipid Profile: Cholestrol……….mg/dl Triglycerides…………….mg/dl

HDL………mg/dl VLDI…..mg/dl LDL………..mg/dl
X-Ray Chest PA Nos……………………..dated………….Report NAD/

ECG No………………….dated…………. Report………………………..

17 (a) Physical Capicity

(i) Height…………….cm (ii) Weight Actual………..kg (iii) Ideal Wt……kg (iv) Over Wt……….%

(v) Waist………cm (vi) Chest Full Expiration…….cm (vii) Range of Expansion………..cm

-----------------------------------------------------------------------------------------------------------------------------------------------------
(b) Cardio Vascular System
(i) Pulse……./m (ii) BP…………..mm/Hg (iii) Peripheral Pulsations NAD/

(iv) Heart Size NAD/ (v) Sounds NAD/ (vi) Rhythm NAD/

(c) Respiratory System

(d) Gastro Intestinal System

(i) Liver Papable (Y/N)………..cm (ii) Spleen Plapable (Y/N)…………..cm

(e) Central Nervous System

(i) Higher Mental Functions NAD/………. (ii) Speech NAD/………. (iii) Reflexes
NAD/…….

(iv) Tremors Nil/Fine/Coarse…………. (v) Self Balancing Test Fairly Steady/Unsteady

-----------------------------------------------------------------------------------------------------------------------------------------------------
Note- Delete what is not applicable, In case any abnormality is detected. Delete ‘NAD’ and enter findines

CONFIDENTIAL
 CONFIDENTIAL

18 (a) Locomotor System (b) Spine NAD/

(c) Hernia NAD/ (d) Hydrocoele NAD/
(e) Hemorrhoids NAD/ (f) Breast

19 (a) Distant Vision R L (b) Near Vision R L (b)

Without Glasses Without Glasses
With Glasses With Glasses

20 (i) Hearing R L Both (c) Authority

Record
FW Cms Cms Cms
FW Cms Cms Cms
(b) Tympanic Membrane Y/N Y/N
Infact
(c) Mobility (valsalva)
(d) Nose, Throat & NAD/
Sinuses

21. Gynecological Exam

(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 NAD/ (h) Prolapse NAD/
(j) USG Abdomen

22. Immunization status (give details)

FINAL OBSERVATIONS & MEDICAL CATEGORY

(Signature of Authorized Medical Attendant

Medical Specialist)

-----------------------------------------------------------------------------------------------------------------------------------------------------
APPROVING/PERUSING AUTHORITY
(Where applicable)

Signature
Rank & Designation
-----------------------------------------------------------------------------------------------------------------------------------------------------

CONFIDENTIAL
 CONFIDENTIAL
A.F.M.S.-3B (Yer-2002)
ANNUAL MEDICAL EXAMINATION

PLACE OF BOARD:_______________________ AUTHORITY: AO/9/2011/DGMS

PERSONAL DATA
1. Number 2. Rank 3. Name 4. Unit/Ship

5. Service 6. Arm/Corps 7. Date of Birth 8. Age

(Army/Navy/Air Force) Branch/Trade

Yrs
9. Type of Commission PC/SSC 10. Date of Commission 11. Total Service Yrs
Applicable
Yrs & Months
12. Past Medical History 13. Present Medical Category

Signature of the officer

Date:

14. Last AME carried out at

EXAMINATION
15 (a) Total No of Teeth Missing/Unsaveable Teeth
(b) Total No of Defective Teeth U.R. 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 U. L.
(c) Total No of Dental Points L.R. 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 L. L.
(d) Condition of Gums Missing teeth to be indicated By Horizontal (-) and
Unsaveable teeth by a cross (x) through the
appropriate number.
Remarks

Date:
16. Investigations

Blood: Hb…………Gm% TLC…….mm3 DLC P…..L……M………E…..B……ESR……..mm full in hour

Urine: RE…… ME……. SP Gravity…………..
………….Albumin…………..Sugar…………….

Blood Sugar: Pasting…………mg/dl 2hrs Post Prandial………………mg/dl

Lipid Profile: Cholestrol……….mg/dl Triglycerided…………….mg/dl

HDL………mg/dl VLDI…..mg/dl MDI………..mg/dl
X-Ray Chest PA Nos……………………..dated………….Report NAD/

ECG No………………….dated…………. Report………………………..

17 (a) Physical Capicity

(i) Hight…………….cm (ii) Weight actual………..kg (iii) Ideal Wt……kg (iv) Over Wt……….%

(v) Waist………cm (vi) Chest Full Expiration…….cm (vii) Range of Expansion………..cm

-----------------------------------------------------------------------------------------------------------------------------------------------------
(b) Cardio Vascular System
(i) Pulse……./m (ii) BP…………..mm/Hg (iii) Peripheral Pulsations NAD/

(iv) Heart Size NAD/ (v) Sounds NAD/ (vi) Rhythm NAD/

(c) Respiratory System

(d) Gastro Intestinal System

(i) Liver Papable (Y/N)………..cm (ii) Spleen Plapable (Y/N)…………..cm

(e) Central Nervous System

(i) Higher Mental Functions NAD/………. (ii) Speech NAD/………. (iii) Reflexes NAD/…….

(iv) Tremors Nil/Fine/Coarse…………. (v) Self Balancing Test Fairly Steady/Unsteady

Note- Delete what is not applicable, In case any abnormality is detected. Delete ‘NAD’ and enter findines
-----------------------------------------------------------------------------------------------------------------------------------------------------
CONFIDENTIAL
 CONFIDENTIAL

18 (a) Lacomotor System (b) Spine NAD/

(c) Hernia NAD/ (d) Hydorcele NAD/
(e) Hecmorrholds NAD/ (f) Breas

19 (a) Distant Vision R L (b) Near Vision R L (b)

Without Glasses Without Glasses
With Glasses With Glasses

20 (i) Hearing R L Both (c) Authority Record

FW Cms Cms Cms
FW Cms Cms Cms
(b) Thmpanic Membranch Y/N Y/N
Infact
(c) Mobility (valsalva)
(d) Nose, Throat & Sinuss NAD/

21. Gynaecological Exam

(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 NAD/ (h) Prolapse NAD/
(j) USG Abdomen

Inumization status (give details)

-----------------------------------------------------------------------------------------------------------------------------------------------------

FINAL OBSERVATIONS & MEDICAL CATEGORY

(Signature of Authorised Medical Attendant)

Medical Specialist

-----------------------------------------------------------------------------------------------------------------------------------------------------
APPROVING/PEPUSING AUTHORITY
(Where applicable)

Signature
Rank & Designation
-----------------------------------------------------------------------------------------------------------------------------------------------------

CONFIDENTIAL
 CONFIDENTIAL
A.F.M.S.-3B (Yer-2003)
ANNUAL MEDICAL EXAMINATION

MEDICAL EXAMINATION HELD AT: MH NASIRABAD (RAJ) AUTHORITY: AO/09/2011/DGMS

PERSONAL DATA
1. Number 2. Rank 3. Name 4. Unit/Ship

MR-07784P Lt Col Mamta Acharya MH Nasirabad

5. Service 6. Arm/Corps 7. Date of Birth 8. Age

(Army/Navy/Air Force) Branch/Trade
39Yrs
Army AMC/Med Offr 23 Oct 1975
9. Type of Comissio 10. Date of Commission 11. Total Service 16 Yrs
PC/SSC Applicable 19 Jun 1999
PC
12. Past Medical History 13. Present Medical Category

SHAPE-1A SHAPE-1A
Signature of the officer
Date: Jan 2015

14. Last AME carried out at MH, Agra on 20 Jan 2014

EXAMINATION
15 (a) Total No of Teeth Missing/Unsaveable Teeth
(b) Total No of Defective Teeth U.R. 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 U.
L.
(c) Total No of Dental Points L.R. 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
L. L.
(d) Condition of Gums Missing teeth to be indicated By Horizontal (-)
and
Unsaveable teeth by a cross (x) through the
appropriate number.
Remarks

Date:
16. Investigations

Blood: Hb…………gm% TLC…….mm3 DLC P…..L……M………E…..B……ESR……..mm full in hour

Urine: RE…… ME……. Sp Gravity…………..
………….Albumin…………..Sugar…………….

Blood Sugar: Fasting…………mg/dl 2hrs Post Prandial………………mg/dl

Lipid Profile: Cholestrol……….mg/dl Triglycerides…………….mg/dl

HDL………mg/dl VLDI…..mg/dl LDL………..mg/dl
X-Ray Chest PA Nos……………………..dated………….Report NAD/

ECG No………………….dated…………. Report………………………..

17 (a) Physical Capicity

(i) Height…………….cm (ii) Weight Actual………..kg (iii) Ideal Wt……kg (iv) Over Wt……….%

(v) Waist………cm (vi) Chest Full Expiration…….cm (vii) Range of Expansion………..cm

-----------------------------------------------------------------------------------------------------------------------------------------------------
(b) Cardio Vascular System
(i) Pulse……./m (ii) BP…………..mm/Hg (iii) Peripheral Pulsations NAD/

(iv) Heart Size NAD/ (v) Sounds NAD/ (vi) Rhythm NAD/

(c) Respiratory System

(d) Gastro Intestinal System

(i) Liver Papable (Y/N)………..cm (ii) Spleen Plapable (Y/N)…………..cm

(e) Central Nervous System

(i) Higher Mental Functions NAD/………. (ii) Speech NAD/………. (iii) Reflexes
NAD/…….

(iv) Tremors Nil/Fine/Coarse…………. (v) Self Balancing Test Fairly Steady/Unsteady

-----------------------------------------------------------------------------------------------------------------------------------------------------
Note- Delete what is not applicable, In case any abnormality is detected. Delete ‘NAD’ and enter findines

CONFIDENTIAL
 CONFIDENTIAL

18 (a) Lacomotor System (b) Spine NAD/

(c) Hernia NAD/ (d) Hydrocoele NAD/
(e) Hecmorrholds NAD/ (f) Breas

19 (a) Distant Vision R L (b) Near Vision R L (b)

Without Glasses Without Glasses
With Glasses With Glasses

20 (i) Hearing R L Both (c) Authority

Record
FW Cms Cms Cms
FW Cms Cms Cms
(b) Thmpanic Y/N Y/N
Membranch Infact
(c) Mobility (valsalva)
(d) Nose, Throat & NAD/
Sinuss

21. Gynaecological Exam

(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 NAD/ (h) Prolapse NAD/
(j) USG Abdomen

22. Inumization status (give details)

FINAL OBSERVATIONS & MEDICAL CATEGORY

(Signature of Authorised Medical Attendant

Medical Specialist)

-----------------------------------------------------------------------------------------------------------------------------------------------------
APPROVING/PERUSING AUTHORITY
(Where applicable)

Signature
Rank & Designation
-----------------------------------------------------------------------------------------------------------------------------------------------------

CONFIDENTIAL
CONFIDENTIAL

A.F.M.S.-3B (Yer-2003)
ANNUAL MEDICAL EXAMINATION

PLACE OF BOARD: MH NASIRABAD (RAJ) AUTHORITY: AO/1/2004/DGMS

PERSONAL DATA
1. Number 2. Rank 3. Name 4. Unit/Ship
IC-72866L
Maj Mukesh Kumar K 212 Rkt Regt (Kargil)

5. Service 6. Arm/Corps 7. Date of Birth 8. Age Yrs

(Army/Navy/Air Force) Branch/Trade
Regt of Arty 07 Sep 1983 30 Yrs 05 Months

9. Type of Comissio PC/SSC 10. Date of Commission 11. Total Service Yrs
Applicable : PC
18 Mar 2006 08 Years

12. Past Medical History 13. Present Medical Category

SHAPE-I SHAPE-I Signature of the officer

Date :

14. Last AME carried out at last AME Report

EXAMINATION
15 (a) Total No of Teeth Missing/Unsaveable Teeth
(b) Total No of Defective Teeth U.R. 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 U. L.
(c) Total No of Dental Points L.R. 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 L. L.
(d) Condition of Gums Missing teeth to be indicated By Horizontal (-) and
Unsaveable teeth by a cross (x) through the
appropriate number.

Remarks

Date:
16. Investigations

Blood: Hb…………Gm% TLC…….mm3 DLC P…..L……M………E…..B……ESR……..mm full in hour

Urine: RE…… ME……. SP Gravity…………..
………….Albumin…………..Sugar…………….

Blood Sugar: Pasting…………mg/dl 2hrs Post Prandial………………mg/dl

Lipid Profile: Cholestrol……….mg/dl Triglycerided…………….mg/dl

HDL………mg/dl VLDI…..mg/dl MDI………..mg/dl
X-Ray Chest PA Nos……………………..dated………….Report NAD/

ECG No………………….dated…………. Report………………………..

17 (a) Physical Capicity

(i) Hight…………….cm (ii) Weight actual………..kg (iii) Ideal Wt……kg (iv) Over Wt……….%

(v) Waist………cm (vi) Chest Full Expiration…….cm (vii) Range of Expansion………..cm

-----------------------------------------------------------------------------------------------------------------------------------------------------
(b) Cardio Vascular System
(i) Pulse……./m (ii) BP…………..mm/Hg (iii) Peripheral Pulsations NAD/

(iv) Heart Size NAD/ (v) Sounds NAD/ (vi) Rhythm NAD/

(c) Respiratory System

(d) Gastro Intestinal System

(i) Liver Papable (Y/N)………..cm (ii) Spleen Plapable (Y/N)…………..cm

(e) Central Nervous System

(i) Higher Mental Functions NAD/………. (ii) Speech NAD/………. (iii) Reflexes NAD/…….

(iv) Tremors Nil/Fine/Coarse…………. (v) Self Balancing Test Fairly Steady/Unsteady

Note- Delete what is not applicable, In case any abnormality is detected. Delete ‘NAD’ and enter findines
-----------------------------------------------------------------------------------------------------------------------------------------------------
CONFIDENTIAL
 CONFIDENTIAL

18 (a) Lacomotor System (b) Spine NAD/

(c) Hernia NAD/ (d) Hydorcele NAD/
(e) Hecmorrholds NAD/ (f) Breas

19 (a) Distant Vision R L (b) Near Vision R L (b)

Without Glasses Without Glasses
With Glasses With Glasses

20 (i) Hearing R L Both (c) Authority Record

FW Cms Cms Cms
FW Cms Cms Cms
(b) Thmpanic Membranch Y/N Y/N
Infact
(c) Mobility (valsalva)
(d) Nose, Throat & Sinuss NAD/

21. Gynaecological Exam

(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 NAD/ (h) Prolapse NAD/
(j) USG Abdomen

Inumization status (give details)

-----------------------------------------------------------------------------------------------------------------------------------------------------

FINAL OBSERVATIONS & MEDICAL CATEGORY

(Signature of Authorised Medical Attendant)

Medical Specialist

-----------------------------------------------------------------------------------------------------------------------------------------------------
APPROVING/PEPUSING AUTHORITY
(Where applicable)

Signature
Rank & Designation
-----------------------------------------------------------------------------------------------------------------------------------------------------

CONFIDENTIAL
 CONFIDENTIAL
A.F.M.S.-3B (Yer-2003)
ANNUAL MEDICAL EXAMINATION
PLACE OF BOARD: MH NASIRABAD (RAJ) AUTHORITY: AO/1/2004/DGMS
PERSONAL DATA
1. Number 2. Rank 3. Name 4. Unit/Ship

NR-21442M Maj Akanksha Sharma MH Nasirabad

5. Service 6. Arm/Corps 7. Date of Birth 8. Age

(Army/Navy/Air Force) Branch/Trade

Army MNS 03 Aug 1983 31 Yrs

9. Type of Comissio PC/SSC 10. Date of Commission 11. Total Service Yrs
Applicable
PC 25 Aug 2005 09 Yrs
12. Past Medical History 13. Present Medical Category

SHAPE-1 SHAPE-1 Signature of the officer

Date :

14. Last AME carried out at MH Nasirabad

EXAMINATION
15 (a) Total No of Teeth Missing/Unsaveable Teeth
(b) Total No of Defective Teeth U.R. 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 U. L.
(c) Total No of Dental Points L.R. 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 L. L.
(d) Condition of Gums Missing teeth to be indicated By Horizontal (-) and
Unsaveable teeth by a cross (x) through the
appropriate number.
Remarks

Date:
16. Investigations

Blood: Hb…………Gm% TLC…….mm3 DLC P…..L……M………E…..B……ESR……..mm full in hour

Urine: RE…… ME……. SP Gravity…………..
………….Albumin…………..Sugar…………….

Blood Sugar: Pasting…………mg/dl 2hrs Post Prandial………………mg/dl

Lipid Profile: Cholestrol……….mg/dl Triglycerided…………….mg/dl

HDL………mg/dl VLDI…..mg/dl MDI………..mg/dl
X-Ray Chest PA Nos……………………..dated………….Report NAD/

ECG No………………….dated…………. Report………………………..

17 (a) Physical Capicity

(i) Hight…………….cm (ii) Weight actual………..kg (iii) Ideal Wt……kg (iv) Over Wt……….%

(v) Waist………cm (vi) Chest Full Expiration…….cm (vii) Range of Expansion………..cm

-----------------------------------------------------------------------------------------------------------------------------------------------------
(b) Cardio Vascular System
(i) Pulse……./m (ii) BP…………..mm/Hg (iii) Peripheral Pulsations NAD/

(iv) Heart Size NAD/ (v) Sounds NAD/ (vi) Rhythm NAD/

(c) Respiratory System

(d) Gastro Intestinal System

(i) Liver Papable (Y/N)………..cm (ii) Spleen Plapable (Y/N)…………..cm

(e) Central Nervous System

(i) Higher Mental Functions NAD/………. (ii) Speech NAD/………. (iii) Reflexes NAD/…….

(iv) Tremors Nil/Fine/Coarse…………. (v) Self Balancing Test Fairly Steady/Unsteady

Note- Delete what is not applicable, In case any abnormality is detected. Delete ‘NAD’ and enter findines
-----------------------------------------------------------------------------------------------------------------------------------------------------
CONFIDENTIAL
 CONFIDENTIAL
2

18 (a) Lacomotor System (b) Spine NAD/

(c) Hernia NAD/ (d) Hydorcele NAD/
(e) Hecmorrholds NAD/ (f) Breas

19 (a) Distant Vision R L (b) Near Vision R L (b)

Without Glasses Without Glasses
With Glasses With Glasses

20 (i) Hearing R L Both (c) Authority Record

FW Cms Cms Cms
FW Cms Cms Cms
(b) Thmpanic Membranch Y/N Y/N
Infact
(c) Mobility (valsalva)
(d) Nose, Throat & Sinuss NAD/

21. Gynaecological Exam

(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 NAD/ (h) Prolapse NAD/
(j) USG Abdomen

Inumization status (give details)

-----------------------------------------------------------------------------------------------------------------------------------------------------

FINAL OBSERVATIONS & MEDICAL CATEGORY

(Signature of Authorised Medical Attendant)

Medical Specialist

-----------------------------------------------------------------------------------------------------------------------------------------------------
APPROVING/PEPUSING AUTHORITY
(Where applicable)

Signature
Rank & Designation
-----------------------------------------------------------------------------------------------------------------------------------------------------

CONFIDENTIAL

CONFIDENTIAL
A.F.M.S.-3B (Yer-2003)
 ANNUAL MEDICAL EXAMINATION

PLACE OF BOARD: MH NASIRABAD (RAJ) AUTHORITY: AO/1/2004/DGMS

PERSONAL DATA
1. Number 2. Rank 3. Name 4. Unit/Ship

MR-05695-X Col Sanjay Bhasin MH Nasirabad

5. Service 6. Arm/Corps 7. Date of Birth 8. Age

(Army/Navy/Air Force) Branch/Trade

Army AMC/Med Offr 24 Mar 1964 47 Yrs

9. Type of Comissio PC/SSC 10. Date of Commission 11. Total Service Yrs
Applicable
PC 06 Mar 1987 24 Yrs & 02 Months
12. Past Medical History 13. Present Medical Category

CORONARY ARTERY S1H1A1P2E1

DISEASE, ANTERIOR Signature of the officer
WALL MYOCARDIAL Date :
INFARCTION, DVD (POST
PAMI-LAD)
14. Last AME carried out at MH Nasirabad
EXAMINATION
15 (a) Total No of Teeth Missing/Unsaveable Teeth
(b) Total No of Defective Teeth U.R. 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 U. L.
(c) Total No of Dental Points L.R. 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 L. L.
(d) Condition of Gums Missing teeth to be indicated By Horizontal (-) and
Unsaveable teeth by a cross (x) through the
appropriate number.
Remarks

Date:
16. Investigations

Blood: Hb…………Gm% TLC…….mm3 DLC P…..L……M………E…..B……ESR……..mm full in hour

Urine: RE…… ME……. SP Gravity…………..
………….Albumin…………..Sugar…………….

Blood Sugar: Pasting…………mg/dl 2hrs Post Prandial………………mg/dl

Lipid Profile: Cholestrol……….mg/dl Triglycerided…………….mg/dl

HDL………mg/dl VLDI…..mg/dl MDI………..mg/dl
X-Ray Chest PA Nos……………………..dated………….Report NAD/

ECG No………………….dated…………. Report………………………..

17 (a) Physical Capicity

(i) Hight…………….cm (ii) Weight actual………..kg (iii) Ideal Wt……kg (iv) Over Wt……….%

(v) Waist………cm (vi) Chest Full Expiration…….cm (vii) Range of Expansion………..cm

-----------------------------------------------------------------------------------------------------------------------------------------------------
(b) Cardio Vascular System
(i) Pulse……./m (ii) BP…………..mm/Hg (iii) Peripheral Pulsations NAD/

(iv) Heart Size NAD/ (v) Sounds NAD/ (vi) Rhythm NAD/

(c) Respiratory System

(d) Gastro Intestinal System

(i) Liver Papable (Y/N)………..cm (ii) Spleen Plapable (Y/N)…………..cm

(e) Central Nervous System

(i) Higher Mental Functions NAD/………. (ii) Speech NAD/………. (iii) Reflexes NAD/…….

(iv) Tremors Nil/Fine/Coarse…………. (v) Self Balancing Test Fairly Steady/Unsteady

Note- Delete what is not applicable, In case any abnormality is detected. Delete ‘NAD’ and enter findines
-----------------------------------------------------------------------------------------------------------------------------------------------------
CONFIDENTIAL
 CONFIDENTIAL

18 (a) Lacomotor System (b) Spine NAD/

(c) Hernia NAD/ (d) Hydorcele NAD/
(e) Hecmorrholds NAD/ (f) Breas

19 (a) Distant Vision R L (b) Near Vision R L (b)

Without Glasses Without Glasses
With Glasses With Glasses

20 (i) Hearing R L Both (c) Authority Record

FW Cms Cms Cms
FW Cms Cms Cms
(b) Thmpanic Membranch Y/N Y/N
Infact
(c) Mobility (valsalva)
(d) Nose, Throat & Sinuss NAD/

21. Gynaecological Exam

(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 NAD/ (h) Prolapse NAD/
(j) USG Abdomen

Inumization status (give details)

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FINAL OBSERVATIONS & MEDICAL CATEGORY

(Signature of Authorised Medical Attendant)

Medical Specialist

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APPROVING/PEPUSING AUTHORITY
(Where applicable)

Signature
Rank & Designation
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A.F.M.S.-3B (Yer-2003)
ANNUAL MEDICAL EXAMINATION

MEDICAL EXAMINATION HELD AT: MH NASIRABAD (RAJ) AUTHORITY: AO/09/2011/DGMS

PERSONAL DATA
1. Number 2. Rank 3. Name 4. Unit/Ship

MS- 16758P R-05568H MAJ DAIPAYAN GHOSH Brig MH Nasirabad SK Sharma

MH Nasirabad

5. Service 6. Arm/Corps 7. Date of Birth 8. Age 39 Yrs 04 Months

(Army/Navy/Air Force) Branch/Trade Sex (M/F) Male
Army AMC 017 Nov 1977 ul 1960 55 Yrs 11 Months

9. Type of Commission 10. Date of Commission 11. Total Service: 06 Yrs 07 Months
PC/SSC Applicabl 20081010 Oct 2010 29 Yrs 03 Months

12. Past Medical History 13. Present Medical Category

APE-
1 SHAPE- 1 SHAPE-1 SHAPE-1 Signature of the officer
Date: Mar 2017

14. Last AME carried out at MH Nasirabad on 11 Mar 2016

EXAMINATION
15 (a) Total No of Teeth Missing/Unsaveable Teeth
(b) Total No of Defective Teeth U.R. 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 U.
L.
(c) Total No of Dental Points L.R. 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
L. L.
(d) Condition of Gums Missing teeth to be indicated By Horizontal (-)
and
Unsaveable teeth by a cross (x) through the
appropriate number.
Remarks

Date:
16. Investigations

Blood: Hb…………gm% TLC…….mm3 DLC P…..L……M………E…..B……ESR……..mm full in hour

Urine: RE…… ME……. Sp Gravity…………..
………….Albumin…………..Sugar…………….

Blood Sugar: Fasting…………mg/dl 2hrs Post Prandial………………mg/dl

Lipid Profile: Cholestrol……….mg/dl Triglycerides…………….mg/dl

HDL………mg/dl VLDI…..mg/dl LDL………..mg/dl
X-Ray Chest PA Nos……………………..dated………….Report NAD/

ECG No………………….dated…………. Report………………………..

17 (a) Physical Capicity

(i) Height…………….cm (ii) Weight Actual………..kg (iii) Ideal Wt……kg (iv) Over Wt……….%

(v) Waist………cm (vi) Chest Full Expiration…….cm (vii) Range of Expansion………..cm

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(b) Cardio Vascular System
(i) Pulse……./m (ii) BP…………..mm/Hg (iii) Peripheral Pulsations NAD/

(iv) Heart Size NAD/ (v) Sounds NAD/ (vi) Rhythm NAD/

(c) Respiratory System

(d) Gastro Intestinal System

(i) Liver Papable (Y/N)………..cm (ii) Spleen Plapable (Y/N)…………..cm

(e) Central Nervous System

(i) Higher Mental Functions NAD/………. (ii) Speech NAD/………. (iii) Reflexes
NAD/…….

(iv) Tremors Nil/Fine/Coarse…………. (v) Self Balancing Test Fairly Steady/Unsteady

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Note- Delete what is not applicable, In case any abnormality is detected. Delete ‘NAD’ and enter findines

CONFIDENTIAL
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18 (a) Locomotor System (b) Spine NAD/

(c) Hernia NAD/ (d) Hydrocoele NAD/
(e) Hemorrhoids NAD/ (f) Breast

19 (a) Distant Vision R L (b) Near Vision R L (b)

Without Glasses Without Glasses
With Glasses With Glasses

20 (i) Hearing R L Both (c) Authority

Record
FW Cms Cms Cms
FW Cms Cms Cms
(b) Tympanic Membrane Y/N Y/N
Infact
(c) Mobility (valsalva)
(d) Nose, Throat & NAD/
Sinuses

21. Gynecological Exam

(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 NAD/ (h) Prolapse NAD/
(j) USG Abdomen

22. Immunization status (give details)

FINAL OBSERVATIONS & MEDICAL CATEGORY

(Signature of Authorized Medical Attendant

Medical Specialist)

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APPROVING/PERUSING AUTHORITY
(Where applicable)

Signature
Rank & Designation
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CONFIDENTIAL