Rellance

RETAIL
Pre-Employment Medical Examination

(Prospective employee should fill in Section 1 to 4 Map

The Examining Medical Officer will fill in Section 5 to 6
All details given below will be treated as confidential 2 ou29
Please VMark Where Applicable)
1 PERSONAL DETAILS
First Name Middle Name Surname

DEEPAK N DEEPV Ph-08049606000

Address: * 3 CRo SAPOvAR A SIEE ET TDMIAHBLI
LaiksHMLOVAA PDST, DasANAPUTA HolL TANnA LnRE
NOETH
City BANnALORE _Pin: 5ba123
Birth Place: NAnaMAnLA Birth Date ReligionHINDU
(dd/mm/yyyy)
For post applied
uNMARRIED Marital Status: Married / Unmarried Sex 7F
2 FAMILY HISTORY
Has anyone of your family suffered from

Diabetes Hypertension Heart Disease Arthritis

Tuberculosis Asthma Cancer Epilepsy
Mental or Nervous Disorder Any other disease

IF LIVING IF DEAD
AGE HEALTHI AGE AT DEATH CAUSE OF DEATH
(Good, Bad, Fair)|
Father
NAlnAATU boo D
Mother
Brother (No.) SAUNTHRAMMALeoD
DteSHA koul DAh00p
Sister (No.)
Husband/Wife
Children (No.)

3 PERSONAL HISTORY: Yes No

Are you in good health and capable of full work
Have you ever suffered fromoccupational disease or injury ?
an

Have you everbeen discharged or rejected on medical

grounds?
Types of Previous Occupation (Pl. describe in brief about
company, nature of work, duration in years)

Page I of5
 Reliance -RETAIL

Name of Candidate: DEEPIN

Have you taken any vaccination? Yes/ No (If yes complete / partial)
Have you ever suffered from any of the following (AnNwer Yes or No. if yes, give details)

N N

|Heart disease lypertension

Diabetes Chronic abdominal /digestive disorder
Kidney disease lepatitis-B
Asthma Chronic lung disease (eg. bronchitis,
pleurisy, pneumonia etc.)
Tuberculosis Malaria/Typhoid fever in last 6 months
Dermatitis or any skin disease Venereal or Sexually Transmitted Disease

Epilepsy, Fits, fainting or dizziness Nervous/Mental disease of any kind

Any allergy Any chronic ear or hearing problem (e.g.
sinusitis, rhinitis, otitis etc.)
Any major operation or injury Any other illnesses
|Do you have any physical handicap
Details of any of above if "Yes")

(For female candidates only)

Are you pregnantat present?|YN Date of LM.P.
4 1 declare that the above statements are true and complete to the best of my knowledge and belief and I
agree that the results of this medical examination in general terms may be revealed to the company if
required. I also fully understand that in case I am declared medically unfit due to any reason, I shall not
be entitled for the employment in the company. However, The decision taken by the company's
doctor/s about my medical fitness will be final and binding to me.

Date (dd/mm/yyyy) Signature of Prospéctive/ Employee

5 RESULT OF PHYSICAL EXAMINATION

(Examining doctorshould ensure that candidate has filled up section 1to 4D
Appearance o l a
M WKN Skin
General A
2 Throat l e n _ Tonsils Thyroid lands
3 Ears Hearing (eg. Whisper at 2 meter) Nose
4 Teeth & Gums Tongue AAL
5 Height 64ems Weight95 Girth at Navel Cms
BMI
Chest: Expiration cms Inspiration ems

Page 2 ofS
 Rellance RETAIL

Name of Candidate:
PECPAL N
6 Vision CTobe checked by ere specialist)
Colour Vision (Pls Mark Applicable)
Rt Lt
Distance Normal Colour vision
Without glass
Total Colour Deficiency
Near
NG N Partial Colour Deficiency
With glass Distance
If partial - pl. mention for which colour
Near

Power of lens Spherical

Cylindrical1 Signature of eye specialist

Axis Dr. B. R. PADMANABHA RAO

M.B.B.S.. D.O.M.S.
Yes No Consultant Ophthanic Surgeor
Squint Manipal Hosit.l, MaHeshwar
KMC Rag. No. 15657
Any other eye disease ifyes pl. give details
7 Audiometry Report

8 P.F.T Report

9 Heart Sounds Murmur Present Absent Details if present AA4

Arteries ARLMA Blood Pressure

Sys Dia

Pulse-Rate Character
L78min
10 Lungs clun
11 Abdomen Liver AR Aalpalle Spleen pslyellk
12 Urinary and Genital Organs
Venereal Disease

13 Special Conditions : Flat feet _Varicose Veins

Hernia Deformities
Scars
Identification marks:

14 Nervous System ANENP Pupilary Reaction ELLL.

Planters Knee Jerks Rhomberg +veve
15 Urine:Sp. Gr. 2S_Reaction SAlbumin M Sugar
Microscopic (1f required)
Blood Haemoglobin
7
S. cholesterol
Blood Sugar
86RS/RBS BL Gr.
|/27|mg% s.Trygly. 80 mg% S. Creat. o.3
sBilirubin SGPT 4 units
16 Chest X-ray
AMAL SuD
17 E.C.G

18 Any other Investigations/ clinical finding MA

Page 3 of5
 Reltance -RETAIL
Name of Candidate:
DEGPAKk A
6 COMMENTS AND RECOMMENDATIONS
(Pls Mark Applicable) (please refer standards for recruitment)

PUnft DIET
Remarks:
XEh cesE WEaU7 REvyt7to .
Date (dd/mm/yyyy) Signature with Seal of Examining Doctor

1lo1/P.
Address of Examining Doctor Manipal Hospital
Out Patient Services
#5/2. 13th Cross, 8th
Main.
Malleshwaram, Bengaluru-560 003
Ph.. 080 49006000

Name:
L MMA Registration No:
Contact No: Mobile: K Clinic: kMCL7 R53
Residence:

For office use only:

Date of receipt of original documents:
PEM No.:
MDMS No.:
Medically Fit Temp. Unfit Unfit
Special Remarks:
Verification done by medical officer:
Signature
Name .
Date:
Fitness certificate issued
Yes No Fitness certificate sent on (date)

Page 4 of5
 Uno-3221
ManipalHospitals
UFES ON
MALLESHWARAM
QUESTIONNAIRE
PERSONAL DETAILS

come and pick up

will the Finai Report
MANIPAL HEALTH CHECK Please Courier the Final Report to

Hospital No

Health Check No

Order No

Name DCEPAKN Hosp. No. 569015S

Age 25 Yrs Date of Birth 2 o19 Sex Mate Female

Marital Status Married/Single ... Yes/No

Pregnancy

CompanyReliamc KtailDesignation_ ALPo

Profession Skill Specialization

EMP Code No. 5s 431L

Tel No. (Res) Mobile 9q100L4 O

Email 1D (please wrte clearly) Dezpuhajbnagalafu@qwailCom

Present Address 1 3 2dcho Shova StAtTowiahald:

1kph e Pont B a r NoYHa S62123
Permanent Address

Manipal Northside Hospita

71, 11 Mein, Opp Maieshwaram Raiwey Statn tMatleshwaram
Bangalore 560 003 Phone 080 49007000 Signature
Out Patient Servicess
5/2, 13 Cross Road, 8 Main Road. Malieswaram Date 9 |
Bangaiore 560 003 Phone 080-49006000
 FOR DOCTORS USE ONLY
of Hg
Pulse8_Min B.P12e 6 mm
Henght 6 cms Weight:9 kgs BMI :3

DURATION
CHIEF COMPLAINTS:

HISTORY OF PRESENT ILLNESS

PAST HISTORY

PERSONAL HISTORY
Diet Veg/Non-Veg
Smoking habits
Alcohol habits
Other habits
Exercise : ul
Occupation

PRESENT MEDICATIONS

DRUGALLERGIES
M COWN
FAMILY HISTORY

Hypertension Diabetess
Heart Diseases Cerebro Vascular Disease
Cancers Tuberculosis
Bronchial Asthma Gout
Epilepsy Others

2
 CLINICAL EXAMINATION

Menstrual history (Female) Regular Excessive Scanty Painful

Males Phimosis Testes N Inguino scrotal sweling

Height

Weight Cn

Pulse
7Blma

BP
NAND

CVS SS
RS NVSSt

P/A

Skin

Ear

Nose N

Throat

Eyes N

3
 INVESTIGATIONS

AweMAL
Urine Examination

Stool Examination

Wn
CBC

Blood Biochemical Analysis

X-Ray Chest (PA VIEW) oRMAL S1uey

ECG NSR

Treadmili (stress) Test

Echo Cardiography

Ultrasonography

Special Tests

4
 FINAL IMPRESSION

cltNtCAal
w NL
REPRRTS

ADVICE

BRANco DE1.
N7 LEDUCPA 6y Jol

ALP (N REUANE
hTTO 701 AS
RET41L Co. 1

Manipal Hospital
Out Patient Services
# 5/2 13th Cross. 8th Main,
Mallesh 003

SIGNATURE OF Sr. REGISTER SIGNATURE OF CONSULTANT

DIETRY ADVICE:

SIGNATURE OF DIETICIAN

5
ManipalHospitals
Name :MESARN Age 25 Yr(s) Sex :Male
Registration No MHO05670155 Lab No 101210100229
Patient Episode H80000006772 Collection Date 21 Jan 2021 08:18
Referred By :HEALTH CHECK MHN
Receiving Date :21 Jan 2021 11:46
Reporting Date 21 Jan 2021 12:17

Clinical Laboratory Report

BLOODBANK
TEST RESULT UNIT REFERENCE

Blood Group & Rh Typing (slide agglutination1/tube technique) Specimen-Blood

Blood Group & Rh typing O Rh (D) Positive

Technical note:
ABO grouping and Rh tYping is done by cell and serum grouping by microplate gel techni

- - - - END OF REPORT - - -

Dr Manjula P Biradar MD, DNB

Consultant Pathologist

Manipal Hospital
Out Patient Services
#5/2. 13th Cross. 8th
Main 003
Malleshwaram Bengaluru-560
Ph 080 49006000

This report is based on the specimen/s received. The report may need to be correlated clinically as laboratory
investigations are dependent on multiple variables. These results should not be reproduced in part.

An ISO 9001-2008 certified for Clinical, Nursing, Diagnostics and allied areas
Manipal Northside Hospital, No. 71, 11th Main, Malleshwaram, Bangalore 560 003. Ph:080 4900 7000/00
Out Patient Services: # 5/2,13th Cross Road, 8th Main, Malleshwaram, Bangalore - 560 003. Ph: 080-4900 6000 m o 0

Registered Ofice: Manipal Health Enterprises Pvt Ltd

The Annexe, # 98/2, Rustum Bagh Road, Off HAL Airport Road, Bangalore 560 017 P+91 80 4936 0300 www.manipau NABH
CCREDNED
CIN U85110KA2010PTCO52540
ManipalHospitals
Name M5ERN Age 25 Yr(s) Sex Male
Registration No MHOO5670155 Lab No
Patient Episode
102210101114
H80000006772
Referred By HEALTH CHECK MHN
Colection Date 21 Jan 2021 08:17

Receiving Date 21 Jan 2021 09:15 Reporting Date: 21 Jan 2021 1043

Clinical Laboratory Report

BIOCHEMISTRY
TEST RESULT UNIT REFERENCE

Serum BILIRUBIN- TOTAL (mod. J

Grof f)* 0. 90
mg/
Note: Vary according to age
(days), body wt & gestation of baby
to.10-1.201

Serum TOTAL CHOLESTEROL (CHOD/POD)

187 mg/dl 2001
Moderate risk: 200-239
High risk: >240

Serum SGPT/ ALT

24 IU/L (10-501

Serum TRIGLYCERIDES
(GPO/ POD) 80 mg/dl 150
High: 200 499
Very high: »500
Borderline high: 151-199

SERUM CREATININE (mod.Jaffe)

0..89 mg/dl
eGFR to.80-1.60]
118. 8
ml/min/1.73sq.m 60.01

Disclaimer
eGFR which is
primarily based on Serum Creatinine is a derivation of
EPI 2009 CKD-
equation normalized to1.73 sq.m BSA and is not
eGFR tends to be less accurate when applicable to individuals below 18 years
Serum Creatinine estimation is
patients at extremes of muscle mass, on unusual indeterminate e.g.
diets etc. and
Icterus Lipemia. samples with severe Hemolysis

Plasma GLUCOSE- Fast ing (Hexokinase)

86 mg/dl [70-1001
- - END OF REPORT- - - -

Menipal Hospital
Oatent Services
5/2 13th Cross 8th Ma
Dr ManjulaP Biradar MD, DNB
Consultant Pathologlst

his report is based on the

specimenvs received The repot may need to be correlated clinically as läboratory
investigations are dependent on muitiple vaniables These results should not be reproduced in part
An ISO 9001-2008 certified for
Clinical, Nursing, Diagnostics and allied areas
Manipal Northside Hospital, No. 71, 11th Main, Matleshwaram,
Bangalore 560 003 Ph 080 4900 70OU/D
aent Sevices: # 5/2.13th Cross Road, 8thMain, Malleswaram, Bangalore 560 003 Ph 080 4900 6000 /11/12/13/25
Registered Office Manipal Health Enterprises
Pvt Ltd
82 Rustum Bagh Road. Of HAL Airport Road, Bangalore - 560 017 P 91 80 4936 0300 www.manipalihospitals.com NABH
CIN: U85110KA2010PTCO52540
ManipalHospitals
Name :NdHEESARN Age 25 Yr(s) Sex Male
Registration No : MHOO5670155 Lab No 103210100668
Patient Episode H80000006772 Collection Date: 21 Jan 2021 08:18
Referred By HEALTH CHECK MHN Reporting Date: 21 Jan 2021 10:05
Receiving Date :21 Jan 2021 09:14
Clinical Laboratory Report
HAEMATOLOGY
TEST RESULT UNIT REFERENCE

cOMPLETE BLOOD cOUNT (Automated)

Specimen-EDTA Blood
WBC Count (TC) 6800 /cu.mm [4400-11000)
RBC Count 5..45
Haemoglobin 16.2
million/cu.mm 4.50-6.50]
Haematocrit [PCV]
g/dl 14.0-18.0]
49.3
MCV [42.0-54.0]
90.4 f1
MCH [80.0-96.0]
29.8
MCHC
33.0
Pg [27.0-31.0]
dl (32.0-37.0]
Platelet Count
379000 /cu.mm
RDW (CV) (150000-400000]
13.
MPV [11.6-14.0]
6.9
DIFFERENTIAL COUNT
Neutrophils 61..8
Lymphocytes (40.0-75.0]
28.9 [20.0-45.0]
Monocytes 8..4
Eosinophils 2.0-10.01
0.0
Basophils [o.0-7.0
0..9
[o.0-1.0]
- - END OF REPORT- - - .

Dr Manjula P Biradar
MD, DNB
Consultant Pathologist

Manipal Hospital
Out Patient Se vices
#5/2, 13th Cross btr han
Malleshwara Beigal u-iot
Ph. 0804 Ut JU

This report is based on the specimen/s received. The

report may need to be correlated clinically as
investigations are dependent on multiple variables. These results should not be reproduced in part.laboratory
An ISO 9001-2008 certified for
Clinical, Nursing, OUA
Manipal Northside Hospital, No. 71, 11th Main, Diagnostics
and allied areas
Malleshwaram,
BangaloreBangalore
560 003. Ph: 080 4900 7000/O07
Out Patient Services : # 5/2,13th Cross Road, 8th Main, Malleshwaram, 560 003. Ph: 080- 4900 6000 /11/12/13/o
Registered Office: Manipal Health Enterprises Pvt Ltd
The Annexe, # 98/2,
Rustum Bagh Road, Off
HAL Airport Road, Bangalore 560 017 P+ 91 80 4936 0300
CIN U85110KA201OPTCO52540 www.manipalhospitals.com" NABH
CREDITE
ManipalHospitals
Name MR'BEEPARN
Age 25 Yr(s) Sex :Male
Registration No :MHO05670155 Lab No 108210100242
Patient Episode :H80000006772 Collection Date: 21 Jan 2021 08:18
Referred By : HEALTH CHECK MHN
Reporting Date: 21 Jan 2021 10:05
Receiving Date 21 Jan 2021 09:22
Clinical Laboratory Report
CLINICAL PATHOLOGY

ROUTINE URINE ANALYSIS (Manual method) Specimen-Urine

MACROScOPIC DESCRIPTION
Colour PALE YELLOW (Pale Yellow - Yellow)
Appearance CLEAR
Reaction lpH] 6.5 (4.6-8.8)
Specific Gravity 1.015 (1.015-1.025)
CHEMICAL EXAMINATION
Protein/Albumin Negative (NIL-TRACE)
Glucose NIL (NIL)
Ketone Bodies NIL (NIL)
(NORMAL)
(NEGATIVE)
(NIL)
MICROSCOPIC EXAMINATION
WBC/Pus Cells 2-4 /hpf (4-6)
Red Blood Cells NIL (1-2)
Epithelial Cells 2-4 /hpf (2-4)
Casts NIL (NIL)
Crystals NIL (NIL)

-- END OF REPORT- --

Dr Manjula P Biradar MD, DNB

Consultant Pathologist

Manipal Hospita!
Out Patient Servnes
# 5/2, 13th Cross. bir hair.
Malleshwaram, Benga. u-6t 3
Ph.. 080 490to0

This report is based on the specimen/s received. The report may need to be correlated clinically as laboratory
investigations are dependent on multiple variables. These results should not be reproduced in part.

An ISO 9001-2008 certified for Clinical, Nursing, Diagnostics and allied areas
Manipal Northside Hospital, No. 71, 11thMain, Malleshwaram, Bangalore -560 003. Ph:080-4900 7000/007
Out Patient Services: # 5/2,13th Cross Road, 8th Main, Malleshwaram, Bangalore 560 003. Ph:080 -4900 6000 /11/12/13/40
Registered Office: Manipal Health Enterprises Pvt Ltd WABH
The Annexe, # 98/2, Rustum Bagh Road, Off HALAirport Road, Bangalore - 560 017 P + 91 80 4936 0300 www.manipalhospitais.o CREOEDD
CIN: U85110KA2010PTCO52540
 ManipalHospitals
UFES ON

OUT- PATIENT RECORD- HEALTH CHECK

Name :Mr. Deepak Age/Gender 25 YRS MALE

Hospital No. : MHO05670155 Date & Time 21/01/2021

Consultant Name : DR.PADMANABHA RAO Reg. No.

OPHTHALMIC CHECK UP

VISION: RIGHT l6 RIGHT NG

LEFT Glb LEFT N

COLOUR VISION: Narme

INTRA OCULAR PRESSURE:

NaCM
IsIS
RETINA NO Areal

OPTIC DISCS:

ADVICE:

Dr. B. R. PA MANABHA RAO

M.B BS.. D.O.MS
Consutant Ophthamic Surgeon
Manipal Hospital, Malleshwaram
KMC Reg No. 15657
 i
N

Manipal Hospital
OutPatient Services
# 5/2 13th Cross, 8th Main
Malleshwaram, Bengaluru-560 003
Ph..08049006000
.

.
ManipalHospitals LIFE'S ON H

RADIOLOGY & IMAGING REPORT

Name: DEEPAK N Hospital No: MHO05670155

Age: 25 Sex: M Episode No: H80000006772
Doctor: Health Check MHN Result Date: 21 Jan 2021 10:00

Order: Xray chest PA (CXR)

X-RAY CHEST - PA VIEW

Rotation of chest
Lung fields appear clear bilaterally with normal
bronchovascular markings.

Cardiac silhouette and cardiothoracic ratio appear normal.

Costophrenic angles appear normal on both sides.

Domes of the diaphragm appear normal.

Undertying bony and soft tissue shadows appear normal.

IMPRESSION:
No abnormality noted on the chest radiograph

Manipal Hospital
Out Patient Services
Main,
Cross, 8th
#5/2. 13th Bengaluru-560 003
testraram.

Ph.. 080 49006000

DR ANANDA KUMAR K
Consultant Radiologist, Reg No:36101

Manipal Northside Hospital

inpatient Services, #71, 11th Main, Opp. Malieshwaram Railway Station, Maleshwaram, Bengaluru 560 003 P+91 80 4900 7000/007
Outpatient Services, #5/2, 13th Cross Road, 8th Main Road, Malleshwaram, Bengaluru 560 003 P 91 80 4900 6000/1/12/13/25 CUAL
www.manipalhospitals.com
Registered Office
Manipal Health Enterprises Pvt Ltd
The Annexe, # 98/2, Rustom
Bagh Road, Off HAL Airport Road, Bengaluru 560 017 P +91 80 4936 0300
-

www.manipalhospitals.com NABH
CIN U85110KA2010PTCO52540 CoREDIE