Form P. S. R.
4
G.P.181
GOVERNMENT OF MALAWI
REPORT OF MEDICAL EXAMINATION OF CANDIDATE FOR PERMANENT OR
CONTRACT EMPLOYMENT IN AN ESTABLISHED CIVIL SERVICE POST
Part I: To be completed by Applicant in the presence of the Medical Examiner
Applicant’s name in full ………………………………………………………………………
Address ………………………………………………………………………………………...
Date of birth ……………………………………………………………………………………
DECLARATION
I, the undersigned, do hereby certify that I have carefully considered my answers to questions 1 – 3
below and that, to the best of my knowledge and belief, the information given is complete and correct
(Date) ……………………………………………
(Address) ………………………………………… …………………………..
(Signature of Applicant)
1. Have you ever suffered from any of the following? (Give dates for each “yes” answer)
Yes No Dates
a) Fits or convulsions or sudden loss of consciousness .. ………………………
Severe headaches or migraine .. .. .. ………………………
Head injury or “concussion” .. .. .. ………………………
“Nervous breakdown” .. .. .. .. ………………………
Any other nervous trouble . . .. .. .. ………………………
b) Tuberculosis of the lungs (“consumption”). . .. .. .. ………………………
Spitting of the blood . . . . .. .. ………………………
Bronchitis, pneumonia or pleurisy . . .. .. .. ………………………
Asthma or hay fever .. .. .. .. ………………………
Silicosis .. .. .. .. .. ………………………
c) Heart disease, “weak heart” or strained heart . . .. .. .. ………………………
Fainting attacks or giddiness .. .. .. .. ………………………
Rheumatism or rheumatic fever . . . . .. .. ………………………
Pain in the chest, throat or arm while undertaking
physical effort. . . . .. .. .. ………………………
d) Stomach or bowel complaints . . . . .. .. ………………………
Indigestion or peptic ulcer. . .. .. .. ………………………
Attacks of abdominal pain . . .. .. .. ………………………
e) Kidney or bladder trouble .. .. .. .. ………………………
Syphillis or gonorrhoea . . .. .. .. ………………………
Difficulty or pain in passing urine . . .. .. .. ………………………
f) Malaria .. .. .. .. .. .. ………………………
Dysentry .. .. .. .. .. ………………………
Enteric (typhoid or paratyphoid fever) . . .. .. .. ………………………
Bilhazia (schistosomiasis) . . .. .. .. ………………………
g) Any eye or ear complaints .. .. .. .. ………………………
h) Injury or disease of bones or joints. . .. .. .. ………………………
2
i) Skin diseases .. .. .. .. .. .. ………………………
j) Varicose veins .. .. .. .. .. .. ………………………
2. Have you ever suffered from any other illness or injury not mentioned above?
………………………………………………………………… ………………………
………………………………………………………………… ………………………
3. What operations have you had…………………………….. ………………………
…………………………………………………………… ………………………
Part II: Examination
Height……………………… Weight……………………………………..Chest measurement
(without shoes) (with clothes but without shoes)
(a) on expiration………………………………
(b) on inspiration………………………………
(c) expansion………………………………….
Physical development………………………………………………………………………….
Any physical abnormalities, defects or deformities……………………………………
Mental state…………………………………………………………………………………….
Vision: Right eye without glasses……………………………………………………………..
with glasses…………………………………………………………………
Left eye without glasses……………………………………………………………….
with glasses…………………………………………………………………..
(Snellen’s standard type at 6.096 metres (20 feet) to be used)
Hearing: Right ear…………………………………Left ear…………………………………..
Speech………………………………………………………………………………………….
Cardiovascular system…………………………………………………………………………
Heart: Position of appex beat…………………………………..Rate…………………………
………………………………………………………………………………………….
Sounds………………………………………………………………………………….
Murmurs……………………………………………………………………………….
Rhythm………………………………………………………………………………..
Pulse rate (standing)……………………………………………………………………
Blood pressure: Systolic………………………………Diastolic………………………………
*Exercise tolerance …………………………………………………………………….
*To be tested when considered necessary.
Respiratory system……………………………………………………………………………..
Abdomen
Scars …………………………………………Liver size………………………………
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Spleen enlargement…………………………..Tenderness…………………………….
Hernia…………………………………………………………………………………..
Genito-urinary system
Kidney enlargement…………………………………………………………………….
Urine: Appearance………………………………………………………………………
S.G………………………………………………………………………………………
Albumen………………………………………………………………………………...
Sugar…………………………………………………………………………………….
Deposit………………………………………………………………………………….
.
Bilharzial ova………………...…………………………………………………………
Females
Menstrual history………………………………………………………………………
Part III: Certificate
1. From your examination and observation do you consider that the applicant is-
(a) in good health and fit for any type of employment anywhere in Malawi?
…………………………………………………………………………………………..
(b) fit for specified duties only?……………………………………………………………
Of what nature?…………………………………………………………………………
2.Is the applicant free from any mental or physical defect likely to be aggravated or to
endanger the life, health or safety of himself or herself or others in the course of his/her
employment?
…………………………………………………………………………………………………
…………………………………………………………………………………….
3. Would you pass the applicant as first class life for insurance purposes?
…………………………………………………………………………………………………..
(Date)……………………………………..(Signed)……………………………………………
(Medical Practitioner)
( Address) ………………………… …………………………………..
…………………………………… …………………………………..
…………………………………… …………………………………..
…………………………………… …………………………………..
(Full name and qualification of Medical
Practitioners in block letters)
P. &S. 97133/50M/7.89
