Format for medical examination of prison inmates on admission issued by the National Human Rights Co

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

1. Nervous system

2. Cardio-vascular system

3. Respiratory system

4. Eye

5. ENT

6. Gastro-intestinal

7. Teeth and gums

8. 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