Case No.
Name
Age
Sex
Thumb Impression
Father’s/Husband’s name
Occupation Date and time of admission in the prison
Identification marks
Previous history of illness
Are u suffering from any disease? If so, name the disease
Are you now taking medicines for the same?
Are you suffering from cough that has lasted for 3 weeks or more?
History of drug abuse if any
Any health information the person in custody may volunteer
Physical examination
Height in cm
Weight in kg
Last menstruation period
Pallor
Lymph node enlargement
Clubbing
Cyanosis
Icterus
Injury (if any)
Blood test for Hepatitis/STD including HIV (with informed consent whenver required by law)
Any other
Systemic examination
Nervous system
Cardio-vascular system
Respiratory system
Eye
ENT
Gastro-intestinal
Teeth and gums
Urinary system
The medical examination and investigations were conducted with the consent of the person in custody after explaining to him/her that it was necessary for diagnosis and treatment of the disease from which he/or she maybe suffering
Date of commencement of medical investigation Date of completion of medical investigation
Signature of medical officer
Comments