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GOVERNMENT OF MANIPUR
DEPARTMENT OF SOCIAL WELFARE

Medical Certificate in respect of an Orthopaedically Handicapped Candidate


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

                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 marks:-
3. Sex:
4. Father’s name:
5. Approximate age:;
6. (a) Nature of disability (Tick relevant from following list, Post-Polio Paralysis,
         Hemplegia, Quardappegia, Malunitied Fracture, Nerve Paralysis, Upper Extremity,
         Lower Extremity, Limp, Painfull Sortening, Deformity, Congenital Acquired, Above Knee,
         elow Knee, Hip, Hemipelvectomy Symes, Cheoparts, Wrist, Fingers, Below Elbow,
        Above Elbow, Shoulders, Fore Quarte Unilateral, Bilateral.
   (b) Extent of disability : Estimate in percentages (Mo.BR IDE Scale). On anatomical,
        Functional(Patient’s Assessment, Examiner’s assessment) Economical Basis Mention as
       percentages. (Below 25,25-75,75-90 Total Disability).
   (c) Use of an appliance (Tick relevant from following list), Calliper, Crutch, Above Knee,
       Below Knee, Prosthesis, Cane, Unilateral, Bilateral, Above Elbow, Below Elbow, Hemipelvectomy,
       Shoulder Disarti-culation.
   (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 Surgeon
    might like to point out.



Signature of candidate                                                 (Signature of Orthopaedical Surgeon)
Place :                                                                                     Designation
Date  :                                                                                    Office Stamp
                                                                                              Address