APPENDIX -I PROFORMA FOR HEALTH SCREENING OF PRISONERS ON ADMISSION TO JAIL Case No................................................................................................................................ Name ................................Age............Sex................ Thumb impression...................... Father's/Husband's Name ................................................Occupation .......................... Date & Time of admission in the prison ......................................................................... Identification marks ............................................................................................................ Previous History of illness Are you suffering from any disease? Yes/No If so, the name of the disease : Are you now taking medicines for the same? Are you suffering from cough that has lasted for 3 weeks or more Yes/No History of drug abuse, if any: Any information the prisoner may volunteer: Physical examination: Height...............cms. Weight................. kg. Last menstruation period ....................... 1. Pallor : YES/NO 2. Lymph Node enlargement: YES/NO 3. Clubbing : YES/NO 4. Cyanosis: YES/NO 5. Icterus: YES/NO 6. Injury, if any..................... 4. Blood test for Hepatitis/STD including HIV, (with the informed consent of the prisoner whenever required by law) 5. Any other ............................................................................................................................ Systemic Examination 1. Nervous System 85