Here is something you can work with, that uses fancyhdr to set the header of the page.

\documentclass{article}
\usepackage[headheight=26pt]{geometry}% http://ctan.org/pkg/geometry
\usepackage{lipsum}% http://ctan.org/pkg/lipsum
\usepackage{fancyhdr}% http://ctan.org/pkg/fanychdr
\fancypagestyle{myheader}{%
\fancyhf{}% clear header/footer
\fancyhead[L]{\begin{tabular}{|p{2cm}|*{7}{c|}}
\hline
S.\ Name & \multicolumn{1}{c}{\qquad} & \multicolumn{1}{c}{\qquad} &
\multicolumn{1}{c}{\qquad} & \multicolumn{1}{c}{\qquad} & \multicolumn{1}{c}{\qquad} &
\multicolumn{1}{c}{\qquad} & \multicolumn{1}{c|}{\qquad} \\ \hline
R.\ No & & & & & & & \\
\hline
\end{tabular}%
}
\fancyhead[R]{\begin{tabular}{|*{5}{c|}}
\hline
1 & 2 & 3 & 4 & \phantom{5} \\ \hline
& & & & \\
\hline
\end{tabular}%
}
\renewcommand{\headrulewidth}{0pt}% No header rule
\renewcommand{\footrulewidth}{0pt}% No footer rule
}
\pagestyle{myheader}
\begin{document}
\lipsum
\end{document}
geometry is used to easily modify the page layout, adding the required headheight change to accommodate a double-line tabular in the header. lipsum just provides dummy text.
The MWE above provides a myheader page style which you can set for only one page (using \thispagestyle{myheader}) or globally (as is currently done, via \pagestyle{myheader}). You didn't mention anything about a footer, but that can be added to the myheader page style. For example, adding the page number and/or a rule.
To increase the line width for the header tabulars, include the length setting of \arrayrulewidth in a group inside the respective headers. Also the cell widths can be modified by specifying something like p{5mm}, while the height is adjustable via the inclusion of a vertical "strut" using \rule{0pt}{<height>}:
\usepackage{array}% http://ctan.org/pkg/array
\newcommand{\clap}[1]{\makebox[0pt]{#1}}% Centered zero-width box
%...
\fancypagestyle{myheader}{%
\fancyhf{}% clear header/footer
\fancyhead[L]{{\setlength{\arrayrulewidth}{2pt}%
\begin{tabular}{|p{2cm}|*{7}{c|}}
\hline
\rule{0pt}{1.5em}S.\ Name & \multicolumn{1}{c}{\qquad} & \multicolumn{1}{c}{\qquad} &
\multicolumn{1}{c}{\qquad} & \multicolumn{1}{c}{\qquad} & \multicolumn{1}{c}{\qquad} &
\multicolumn{1}{c}{\qquad} & \multicolumn{1}{c|}{\qquad} \\ \hline
\rule{0pt}{1.5em}R.\ No & & & & & & & \\
\hline
\end{tabular}%
}}
\fancyhead[R]{{\setlength{\arrayrulewidth}{2pt}%
\begin{tabular}{|*{5}{>{\centering\arraybackslash}p{5mm}|}}
\hline
\rule{0pt}{1.5em}\clap{1} & \clap{2} & \clap{3} & \clap{4} & \\ \hline
\rule{0pt}{1.5em} & & & & \\
\hline
\end{tabular}%
}}
\renewcommand{\headrulewidth}{0pt}% No header rule
\renewcommand{\footrulewidth}{0pt}% No footer rule
}
Note the additional braces that groups the contents and avoids it from spilling into the rest of your document. Any of these height adjustments (rule width and struts) should also be accompanied with a change in headheight to accommodate the increase.