"Form IV
(See rule 3]
1..
The All India Services (Pe rformance Appraisal Report) Rules, 2007
PROFORMA FOR HEALTH CHECK UP
Date:
Sex:
A9'
N ame
M/F
A . Investigations Reports
•
Haemogram
1.
Ha emoglobin
(il
TLC
oLC
(ii)
(Hi)
(a) Polymorpl1s
:b) lymphocytes
(e) Eosinaphils
(d) Basophils
(e) Monocytes
(iv\ Periahera! Smear
Urine Examination
2.
Colour
(il
(if) Albumin
(iii) Sugar
(iv) Microscopic Exam.
Blood Sugar
3.
FasllIlg
(i)
I (ii
Post·Prandial
lipid Profile
••
Total Cholesterol
HOL Cholesterol
lDL Cholesterol
~~) VlDL Cholesterol
v
Tng\ycendes
Liver Function
(Q
(ii)
(iii)
5.
•
.
TesiS
(il S. Bilirubin (Total)
(ii) S Bilirubin (Direct)
(iii) S.G.O ,T
I (iv)
6.
S.G .PT
Kidney Function Tes ts
(il
Blood Urea
.
~::~\ S. Cre<Jtimne
iii
S . UriC A.cld
Contd ... 2
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2
Cardiac Profile
7.
S.LDH
C K*MB
(iii) S.CRP
(iV) SGOT
(1)
(ii)
For Man
PSA
(v)
For Women
I (v;) PAP SMEAR
X-Ra -Chest PA View Re
ECG R~ n
USG Abdomen Report
8.
9
10.
rt
TMTRe rt
Mammooraphy Report Women
Gynaecological Health Check Up
(.)
Pelvic Examination
11.
12
13.
(a) Local Examination
(b) P,er vaglflum (PN)
10) Per SpeCUlum
14 .
Surgical Examination
Breast Exammation
(il
Urological Examinatton (For Men Only)
Rectal Examination (For Men Only)
(Ii)
15.
16.
17
.
(ii 1
( iii)
Systemic Examination
0)
Resp System
(ii)
(iii)
CVS
Abdomen
(IV)
CNS
Iv)
(vi)
Locomotor System
Dental Examination
.
.
Eye Examination ·
(;)
Distant Vision
(ii)
Vision w ith Glasses
Colour VISion
(Iii)
(Iv)
Tonometry
Fundus Ex;)mination
(v)
ENT
0)
(ii)
(iii)
(Iv)
.
Oral Cavity
. Nose
Throat
Lary nx
Gontd ... 3
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B. IrILadlcal Report of th. Officer
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C: Summary of Medical Report (only copy of this part Is to be attached t o PAR)
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2.
Any
other remarks based on the health medical check
uo of the officer
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Oale .
Signature of MedIcal Authorily
Designation
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