SRM University Delhi-NCR,
Delhi NCR, Sonepat, Haryana
(Established under Haryana Privates Universities Act 2006 as amended by Act no.8 of 2013)
Plot no-39,
39, Rajiv Gandhi Education City, Post office –P.S Rai-131029,
131029, Sonepat, (Haryana)
Ph-0130-2203700-08, 2121214/15, Toll free: 1800-180-1216, Website
www.srmuniversity.ac.in
CERITIFICATE OF MEDICAL FITNESS
To be obtained only from a Gazetted Government Medical Officer/Medical Officer of a
Government Undertaking.
Please note that this certificate in no other form will be accepted. Medical Certificates issued by
private medical practitioners will not be accepted.
Name:___________________________________________
______________________________________________________
Age: _______________________________________
_______________________________________________________
Space for photograph
Sex:________________________________________
________________________________________________________
&
Father’s Name:____________________________________
________________________________________________
____________
Attested by the
physician
Mother’s Name:___________________________________
_______________________________________________
____________
Any Chronic illness (Past medical history)
history): _________________________________________
_____________________________
__________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
______________________________________________________________________________
Allergies: _________________________________________________________
_____________________________________________________________________
__________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
______________________________________________________________________________
General Physical Appearance and Examination:Examination
Built: ________________________________________________________________________
_____________________________________________________________
Pulse: _____________________________________________________________
________________________________________________________________________
Blood Pressure: _______________________________________________________________
____________________________________________________
Height: ___________________________________________________________
______________________________________________________________________
Weight: ______________________________________________________________________
___________________________________________________________
Clinical Examination:Chest & Respiratory System: ____________________________________________________
Cardiovascular System: _________________________________________________________
Per Abdomen: _________________________________________________________________
Central Nervous System: ________________________________________________________
Investigations:Vision (Left and right with color blindness test):____________________________________
Blood group: __________________________________________________________________
Hb: __________________________________________________________________________
TLC: ________________________________________________________________________
DLC: ________________________________________________________________________
ESR: ________________________________________________________________________
RBS: ________________________________________________________________________
URINE-R/M: _________________________________________________________________
I, certify that I have examined Mr. / Miss …………………………………………, and found
him/her to be medically fit.
Date:
Physician’s Sign & Stamp with Reg. No.
I am aware of the medical data in this card which is absolutely true to the best of my knowledge
and no facts have been hidden to the examining physician.
Signature of Student
Date:
Signature of Parent/Guardian