Insecticides Rules, 1971 - Form XXII

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

Serial No:

Name:

Father's Husband's name:

Full Address:

Sex:

Date of appointment:

Occupation :
(Please specify the nature of duty)

1. Past 2. Present

PAST HISTORY

FAMILY HISTORY

PERSONAL HISTORY

OBSERVATIONS

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.