Age & Fitness Estimation Form

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                                                            LOREA FASHIONWEAR

eqm I m¶gZv wba©viYx dg©

(Age & Fitness Estimation Form)

Avwg ----------------------------------------------------------------- wcZv/¯^vgxt----------------------------------------------------------------- mÁv‡b, †R‡b, ey‡S Avgvi eqm I m¶gZv wba©vi‡bi Rb¨ cÖ‡qvRbxq cix¶vi AbygwZ cÖ`vb Kijvg|

FINDINGS/ djvdj

--------

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1.  □ Height: _{--------------} Feet_{-------------}  Inch               □ D”PZvt_{----------------------} dzU _{--------------}  BwÂ|

    □ Weight: _{----------------------------------}   KG                  □ IRbt_{------------------------------------------} †KwR|

    □ Sex         □ Male   □ Female                             □ wj½    □  cyiyl   □  gwnjv |

    □   As per conversion chart, estimated age is_{------------------------------------------------------------------------} years.

    □  iycvšÍi QK Abyhvqx AvbygvwbK eqm_{--------------------------------------------------------------------------------------------------} eQi|

2. Eruption of Teeth (`šÍ we`viY):

     □ 7/7 & 7/7 (18 Yrs or below)                               □ 7/7 Ges 7/7      (18 eQi eqm A_ev Kg)

     □  8/7 & 8/7 ( 18 Yrs or above)                             □ 8/7 Ges 8/7      (18 eQi eqm A_ev †ekx)

     □ Others: _{----------------------------------------------------------------------------------------------------------------------------------------------}

     □  Ab¨vb¨: _{-----------------------------------------------------------------------------------------------------------------------------------------------}

   □ As per dental history, estimated age is_{-----------------------------------------------------------------------------} years.

   □ `uv‡Zi wnmve Abyhvqx AvbygvwbK eqm_{-----------------------------------------------------------------------------------------------} eQi|

3. Growth of Hair on Chin and Upper Lips (in case of male)

     `vwo I †Mvd e„w× RwbZ weeiYt (cyiy‡li †¶‡Î)

   □ Fully Grown (18 Yrs or above)                  □ cyY© e„w×           (18 eQi eqm A_ev ‡ekx)

   □ Not Fully Grown (17 Yrs or below)      □ cyY© e„w× b‡n      (17 eQi eqm A_ev Kg)

4. Onset of menstruation (for female)

    □…………….year back.

   □ As per secondary symptoms, estimated age is_{---------------------------------------------------------------} years.

   □ Dc‡iv³ j¶Y Abyhvqx Zvi AvbygvwbK eqm_{--------------------------------------------------------------------------------------} eQi|

5. Identification Marks (If any)  : ------------------------------------------------------------------------------------

    mbv³ KiY wPý (hw` _v‡K)                     : ------------------------------------------------------------------------------------

DOCTOR’S COMMENTS  (wPwKrm‡Ki gšÍe¨)

This person is examined by me on _{------------------------------------} based on above findings, apparently-

Dc‡iv³ Z_¨ Ges cix¶vi wfwˇZ_{------------------------------------------------} Zvwi‡L GB e¨w³i-

□ Estimated age: _{-------------------------------} Years.               □ AvbygvwbK eqm_{---------------------------------------} eQi|

□ Fit to carry out normal trade duty in this factory. □ †Kv¤úvbxi ¯^vfvweK Kvh©µg cwiPvjbvq m¶g|

□ Unfit to carry out normal duty.                             □ †Kv¤úvbxi ¯^vfvweK Kvh©µg cwiPvjbvq m¶g bq|

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