FORM XXII
REGISTER OF PERSONS ENGAGED IN CONNECTION WITH INSECTICIDES AND THEIR PERIODICAL MEDICAL EXAMINATION FOR THE YEAR 20_______
[Rule 37]

Serial No._______________

Name ______________________________Age_________

Father's Husband's name_____________________________

Full Address_________________________________________

Sex____________ Identification mark_________________________________

Date of appointment_________________

Occupation _______________________________(Please specify the nature of duty)

                                                                                              1. Past     2. Present

PAST HISTORY

Illness

Poisoning

Allergy

Exposure to pesticides (Compound)

No of years/ reason

Remarks, if any

1

2

3

4

5

6

           

FAMILY HISTORY

Allergy

Psychological disorders

Haemorrhagic disorders

1

2

3

     

PERSONAL HISTORY

Smoking

Alcohol

Other addiction

1

2

3

     

OBSERVATIONS

Medical Examination

Pre- employment examination

End of 1st quarter i.e. after 3 months

After 2nd quarter after 6 months

After 3rd quarter after 9 months

End of year

Remarks

1 2 3 4 5 6 7
             

1. General Examination
General body limit
Weight
Piles
Blood pressure
Respiration
Anaemia
Dadema
Jaundice
Skin condition
Temperature
Fatigability
Sweating
Sleep
Urination

2. Gastro Intestinal
Nausea
Vomiting
Appetite
Taste
Pain in abdomen
Bowel movement
Liver
Spleen

3. Cardio-respiratory
Nasel discharge
Wheeze
Cough
Expectoration
Tightness of chest
Dyspnoea
Palpitation
Heart
Cyanosis
Tachycardia

4. Neuro-muscular
Headache
Dizziness
Irritability
Pulse
Twitchings
Tremors
Convulsion
Paranesthesia
Hallucination
Unconsciousness
Deep reflexes
Superficial reflexes
Coordination

5. Eye
Pupil
Lachrymation
Double vision
Clumped vision

6. Psychological
Temperament
Judgment
Nervousness

7. Kidney
Kidney Condition

8. Investigation
Blood Hb%
Blood D.C.

* Serum cholinesterago
serum Bilirubin
Urine routine examination
Urine microscopic
X-ray of chest

* serum cholinesterage level should be measured in monthly intervals in case of organophosphorus/ carbamatic group of insecticides. General remarks of the doctor in the light of the above examination:

Advice given to:
1. The patient
2. The employer

Steps taken by the Employer as per Doctor's advice:

Signature/ thumb impression of:

1. Doctor

2. Employees:

3.
Employer / Manufacturer

4. Licensing officer at the time of inspection.

N.B. :- In organochlorine group of insecticides the blood residue estimation should be done once a year.