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MEDICAL CERTIFICATE IN RESPECT OF AN ORTHOPAEDICALLY HANDICAPPED CANDIDATE

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For the purpose of scholarship the orthopaedically handicapped are those who have physical   defect of deformity which causes an Interference with the normal functioning of bones, muscles and joints.

 

Certified that I Dr. ……………………………………. Registration  No.…………………….have   this ………………………..day of ……………………..19…. . examined the applicant whose particulars are given below and that he/she falls within the above definition.  

 

1.        Name of Candidate

2.        Identification mark

3.        Sex

4.        Father’s name

5.        Approximate age

6.        (a) Nature of Disability

  

( Tick relevant from following list) 

 

POST-POLIO PARALYSIS, HEMIPLEGIA, QUADRAPLEGIA, MALUNITIED FRACTURE NERVE PARALYSIS UPPER EXTREMITY, LOWER EXTREMITY, LIMP, PAINFUL, SHORTENING, DEFORMITY, CONGENITAL ACQUIRED , ABOVE KNEE BELOW KNEE, HIP, HEMIPLEVE, CTOMYSYMES, CHEOPARTS  WRIST, FINGERS, BELOW ELBOW, ABOVE ELBOW, SHOULDERS, FORE QUARTER UNILATERAL BILATERAL

 

 (b) Extant of Disability:

 

                  Estimate is percentage ( Mc Bride scale)

ON ANATOMICAL FUNCTIONAL (PATIENTS ASSESSMENT, EXAMINER’S ASSESSMENT)  ECONOMICAL BASIS MENTION AS   PERCENTAGES.
(BELOW 25,25-75,75 –90 TOTAL DISABILITY).

 

 

(c )   use of appliance

( Tick relevant from following list)

 

CALLIPER CRUTCH, ABOVE KNEE,   BELOW KNEE, PROSTHESIS CANE, UNILATERAL, BILATERAL, ABOVE ELBOW, BELOW ELBOW HEMIPEL VECTOMY SHOULDER DIS-ARTICULARTION.


(d) ANY OPERATION DONE OR INDICATED.

 

(e)     PHOTOGRAPH ( ATTESTED)

 

To  show the nature of disability  and any appliance if used

7.        Any other particulars to clarify the nature and extent of disability that  the Surgeons might  like to point out.

 

 

 

   (Signature of Orthopaedic Surgeon  )

 

 Signature  of candidate                                                                 Designation

 Place                                                                                          Office Stamp

 Date                                                                                                Address                                    

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