xxxxxxxxxxxxxxxx POLICE STATION
Performa for Health Searching of Prisoner on Admission to Jail
| 1. | Case No. | |
| 2. | Name | |
| 3. | Age | |
| 4. | Sex | |
| 5. | Thumb impression | |
| 6. | Father Name/Husband Name | |
| 7 | Occupation | |
| 8. | Date and Time of Admission in the Prison | |
| 9. | Identification marks a) b) | |
| 10. | Previous History of illness | |
| 11. | Are you suffering from any disease. (yes or no) | |
| 12. | If so the name of the disease | |
| 13. | Are you taking medicines for the name | |
| 14. | Are you suffering from cough that has | |
| 15. | History of drug case if any | |
| 16. | Any information the prisoner may volunteer | |
| 17. | Physical Examination |
- Height ……………Cms
- Weight………….. Kgs
| 1) | Pallor | .. (Yes/ No) |
| 2) | Clubbing | .. (Yes/ No) |
| 3) | Lotoras | .. (Yes/ No) |
| 4) | Lymph made on largamente | .. (Yes/ No) |
| 5) | Cyanosis | .. (Yes/ No) |
| 6) | Injury if any | .. (Yes/ No) |
7) Blood test for hospitals including HIV (with the informed consent of the
Prisoner whenever required by law)
8) Any other system Examination.
- Nervous System
- Cardio Muscular system
- Reparatory system
- Eye. ENT
- Castro Intestinal System Abdomen
- teeth gum
- Unno / Control system
The Medical Examination and investigation were conducted with consent of the prisoners after expositing to him / her that it was necessary for diagnosis and treatment of the disease from which he / she may be suffering.
Date of commencement of
Medical Investigation
Date of completion of
Medical Investigation
xxxxxxxxxxxxxxxxxxxxxx POLICE STATION
Performa for Health Searching of Prisoner on Admission to Jail
| 1. | Case No. 246/2014 U/S 457,380,414,34 IPC. | |
| 2. | Name: Durai.age 47 | |
| 3. | Age : 47/2019 | |
| 4. | Sex: male. | |
| 5. | Thumb impression | |
| 6. | Father Name/Husband name: Sugumar. | |
| 7 | Occupation: | |
| 8. | Date and Time of Admission in the Prison: 08.05.2019. | |
| 9. | Identification marks a) tyJgf;fk; Njhy;gl;ilapy; xU kr;rk;. b) tyJgf;fk; tapw;wpy; xU kr;rk;. | |
| 10. | Previous History of illness | |
| 11. | Are you suffering from any disease. (yes or no) | |
| 12. | If so the name of the disease | |
| 13. | Are you taking medicines for the name | |
| 14. | Are you suffering from cough that has | |
| 15. | History of drug case if any | |
| 16. | Any information the prisoner may volunteer | |
| 17. | Physical Examination |
- Height ……………Cms
- Weight………….. Kgs
| 1) | Pallor | .. (Yes/ No) |
| 2) | Clubbing | .. (Yes/ No) |
| 3) | Lotoras | .. (Yes/ No) |
| 4) | Lymph made on largamente | .. (Yes/ No) |
| 5) | Cyanosis | .. (Yes/ No) |
| 6) | Injury if any | .. (Yes/ No) |
7) Blood test for hospitals including HIV (with the informed consent of the
Prisoner whenever required by law)
8) Any other system Examination.
- Nervous System
- Cardio Muscular system
- Reparatory system
- Eye. ENT
- Castro Intestinal System Abdomen
- teeth gum
- Unno / Control system
The Medical Examination and investigation were conducted with consent of the prisoners after expositing to him / her that it was necessary for diagnosis and treatment of the disease from which he / she may be suffering.
Date of commencement of
Medical Investigation
Date of completion of
Medical Investigation