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APPENDIX III General Orders 9 (a)
REPUBLIC OF ZAMBIA
FORM OF CERTIFICATE OF MEDICAL EXAMINATION
1. TO: …………………………………………………………………………………
2. I hereby certify that I have this day examined:
…………………………………………………………………………………………..
3. Candidate for employment as: …………….…………………………………………
4. In my opinion he/she ………………….…….for service in the Republic of Zambia.
…………………………………………….
MEDICAL OFFICER
……………………………………………. STATION
……………………………………………. DATE
1. To the Head of department in charge of the candidate
2. and (3) to be filled in the Department applying for Medical Certificate
4. Medical Officer to insert Fit/Unfit as the case may be.
5. Reserve to be completed on copy for DMS only.
THIS FORM MAY BE OBTAINED FROM THE DIRECTOR OF MEDICAL SERVICES –
LUSAKA.
TO BE COMPLETED ON CC FOR DSM ONLY
Age ……………….. Height ……………….................……… Weight …………………..................……….
Physique ……………………………….. Mental State: …………..………………...................................…..
Previous illness: ……………………………………………………………………...................................…..
RESPIRATORY SYSTEM: Girth ….....................………….. Full inspiration …….............……………..
(a) Any abnormality on clinical examination ...………………………………………....................................
(b) X-ray of chest (where possible) ……………………………………………….................................…….
CARDIOVASCULAR SYSTEM:
(a) Rate and quality of pulse ……………………………………………………........................................…..
(b) Any cardiac abnormality …………………………………………………........................................……..
(c) Bloodpressure …………………………………………………………….......................................………
(d) Any varicose veins …………………………..……………………….......................................…………..
ALIMENTARY SYSTEM AND ABDOMEN:
(a) Any symptoms: ………………………………………..……........................................…………………..
(b) Condition mouth, teeth and tonsils: …………………………….......................................………………..
(c) Any abnormality of liver or spleen: …………………………………….......................................………..
(d) Any hernias: ……………………………..……………………........................................………………..
(e) Any haemorrhoids: …………………………………………….......................................….……………..
GENITAL URINARY SYSTEM:
(a) Any symptoms or abnormality: ……………………………….......................................……………….…
(b) Urine: ………………………… Sg: …………,.........................… Reaction .............…………………….
Alb: ……………………………… Sugar: ………………………………….…......................................….…
INTEGUMENARY SYSTEM:
(a) Any eruption ulcer: …………………………………………….....................................................………..
CNS:
(a) Any symptoms: …………………………………………………..................................................………..
(b) Patellar reflexes: ………………………………………………….................................................……….
(c) Pupils: ……………………………………………………….................................................…………….
(d) Hearing: …………………………………………………..................................................……………….
(e) Speech: …………………………………………………...............................................……………..……
REMARKS: ……………………………………………………...................................……………………...
…………………………………………………………………...................................…….…………………
DATE: ……………………………… ……………………………...…………...
MEDICAL OFFICER
