Microsoft Word medical form docx

PART II TO BE COMPLETED BY A MEDICAL OFFICER IN LAUTECH HEALTH CENTRE

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medical clearance form

Without glasses R.6/ L.6/
Left Heart
Pharynx Respiratory system

PART II TO BE COMPLETED BY A MEDICAL OFFICER IN LAUTECH HEALTH CENTRE

HEIGHT………………………… (METER)                  WEIGHT……………………………………. (KG)

Visual Acuity:

Without Glasses     R.6/       L.6/

Without glasses     R.6/       L.6/

Eyes     Ears     Circulatory system

Left   Heart

Right Blood pressure

Pharynx       Respiratory system

Teeth     Lungs

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