CERTIFICATE OF PHYSICAL FTTNESS

(To be filled by a Registered Medical practitioner

in the applicant's counky of domicile)

Name of Applicant MD. SHAHIN PARVEZ

Sex IvLrF

TINMARRIED
Marital Status
23 YEARS B+
Age Blood Croup

BANGLADES}II
Nationality

HOLDING NO.505, YILLAGE: KULCIIAR \ pOST:

BHATAI BAZAR-7320, IJPAZILLA: SHAILKUPA"
Address DISTRICT: JHENIDAH

JHENIDAH
(City)
(Country) BANGLADESH

+8801948086759
Telephone No.
Shahin.bsmrstu I 3@gmail. com
Email Address
I' Medical History (Please give details of any past medical condition which may adversely
impact
the patient's health at the c*rrent time or inthe near future).

IA. Hisfory of Any Known Illness / $urgery: ,

-
Raised BP yes
[-l Nc |7l If, yes - on Regurar treatuent - yes ]fl tf
DM- Yes l-l No lirl I{ yes - on Regular fieatment - yes No l--l l
IHD - Yes [-] xo I7l I{ yes - -
cn Regular feafinent yes lfil
tf
Stroke - Yes l-l No llZI I{ yes - on Regular treatnert - yes
fr tf
Kidney Disease:

chronie Renal Failure - Yes fl mf?It, yes - on Regular freatment - yes fl NolJ
Any history of surgery / prolcnged hospifalization
{more than 2 weeks)
Yes/]r{o; if yes, details of illness / rnjury / surgery with duration ofillness/ treatment

Any history ofloss of appetite - yes tf No F4

Ariy hisrory of loss of Weight - yes t: No FZI
Any history of digestive diseases - yes f] No [t
Farnily History of: DM[?l HT m Obesity IFI
Any known Allergy: - If so, is the patient on any medication / precautions?
 n. Physical Examination

ftIedical coudition of: -

Height _jt-6, Weight 68ke Chest 32"-34,

Head IToRMAL Nose Nonu.qt " Lungs NoRMAL
Eyes Nonnrer Pharyn N0RMAL Heart NoRMAL
Ears NoRuat Neck Noruraet _Reflexes NORMAL
Remarks if any: -
UI' Medical Examination: - Routine Blood, (incfuding Fasting & p.p), Urine Test
and Chest X-Ray
and any other test as deemed fit by the Medical practitioner rule out
[to any chronic disease).

fV, Summary
1' I believe this applicant Is / IS NoT physically able to carry on a fiilI course of
study, involving long hours
of work, in a college or universi{r in fnAia.

7- In my opinion the applicant's health and physical condition in general are:

Excellenty'

Good Poor

J.
l-.dt rB] th" applicant is up-to-date on routine vaccinations including, among others, MMR, DpT,
Varicell4 Hepatitis A & B etc.

4. &' lShe has no physical condition / aliment whiqh would hinder him from pursuing a full course of study in
India.
-Ve ()
5' { U" /She present no evidence of any communicable disease or of any chronic fatigue.
-Ve ()
6' .ltle t She does not have any chronic medical condition which requires regular and nrstained medical
treatrrent.
ve( )
NOTE: If answers to 4, 5 and 6 above are positive, please give details in Remarks
column belqrv^ t

XEMARKS
D*te:te1ot/zora '#kfi+$#'"1
signature#ajsq$i'
Address Med;e^J 0liicen
0sMRsru, arop4bH .

IMPORTANT:

As a protective measurglhose planning to study in India are strongly advised get

to
vaccinated against typhoid I cholera before co*iog to rndia.