Pemfis Ecg Spirometry

Jl.
Canggai Putri, Teluk Uma

Kabupaten Karimun
Telp ( 0777 ) 7367085, 7367176
Fax ( 0777 ) 7367085
Date: Full Name : Date of birth: Company: Occupation:

TN. MUH HERLAMBANG ANGGORO PT PASIFIK TIMUR ECG REPORT
27.02.2024 21.11.1997 HSE OFFICER
ADI ENERGINDO
Jl. Canggai Putri, Teluk Uma
Kabupaten Karimun
Telp ( 0777 ) 7367085, 7367176
Fax ( 0777 ) 7367085
Date: Full Name : Date of birth: Company: Occupation:

TN. MUH HERLAMBANG PT PASIFIK TIMUR SPIROMETRY REPORT
27.02.2024 21.11.1997 HSE OFFICER
ANGGORO ADI ENERGINDO
MEDICAL REPORT Jl. Canggai Putri, Tl.Uma, Karimun
Telp (0777)7367085, 7367176
1 . PERSONAL HISTORY
Name in full Date of birth Sex
Occupation Badge No. Blood Group Rh
Please tick box Yes No Detail if "yes"

( Including dates and duration any other relevant
1 a) Are you at present under medical care or receiving treatment ? information )
b) Are you currently taking medication, prescribed or not,
heaving injection, using an inhaler or have you recently done
so, or are you on a special diet ?
2 Have you ever suffered from :
a) Fits, fainting, giddiness or any mental or nerveus disorder ?
b) Asthma, bronchitis, pneumonia or any other lung disorder ?
c) Rheumatism, rheumatic fever, arthritis or any other disorder

of joints and muscle ?
d) Chest pain, shortness of breath, palpitation, high blood
pressure or other disorders of the heart or circulation ?
e) Indigestion, peptic ulcer, diarrhoea, constipation or any
intestinal complaint, hepatitis or other liver disorders, diabetes
f) Kidney, bladder o other genito-urinary disorders ?
g) Any injury, operation, physical defect or deformity ?
h) Any other illness not mentioned above ?
3 a) Have you ever been a patient at a hospital, nursing home

or special clinic ?
b) Have you ever had any medical investigation carried out ?
4 Have you ever had any form of sexually transmitted disease `

or is there anything about your lifestyle which could expose
you to the risk of AIDS or AIDS related condition ?
5 Female only : Have you ever had any gynaecological or
obstetric problems ?
6 Have you ever taken drugs other than prescribed by any
doctor ?
7 a) Non-smoker : Have you smoked in the past ?
b) Smokers : How much do you smoke per day ? Cigarettes Cigars Pipes
Number smoked pieces/day
c) What is the average daily concumption of alcohol ?
2 . FAMILY MEDICAL HISTORY

If living, age State of health if dead, age at deat Cause of death
Father
Mother
Brother / Sister
Brother / Sister
Brother / Sister
I declare to the best of my knowledge ang belief the answers to the above quastion are true and complate. I comfirm that I have checked and found correct any answers that are not in my handwriting.
I grant permission to take samples of blood, saliva and or urine in connection with this examination. I understant that this statement will be forwarded to the Company's medical Department.
(to be signed in the presence of Medical Examiner)

Telp (0777)7367085, 7367176
3 . SUMMARY OF MEDICAL HISTORY OF

Has the applicant ever had or has now any of the following ? If yes, give details in the summary description
Please, tick box, whether normal or not Yes No Yes No
1 Ear infection / Sinusitis / Vertigo 8 Endocrine disorder
2 Nose, mouth or throat trouble 9 Hernia / Hydrocele / Piles / Fissures
3 Color blindness / Loss Vision 10 Fistula / Appendicitis / Varicocele
4 Frequent headaches / Fainting 11 Malaria / Tropical Disease
5 Epilepsy / Mental illness 12 Skin disease
6 Hypertension 13 Cance or tumor
7 Diabetes mellitus 14 Allergy to foods / drugs
Remarks :
4 . MEDICAL EXAMINER'S REPORT

If you answer Yes to any of the following question, please give full details with any ascertainable cause as applicable
Please tick box Yes No Detail if "yes"

8 Measurement & Physical Description
a) Measurements (to be taken in indoor clothing) Height cm Weight kg
b) Please describe general appearance and build : BMI = Weist :
c) Are there any signs of past or present over-indulgence

In alcohol, tobaco, or irregular lifestyle
d) Is there any enlargement of lymph nodes or thyroid gland ?
e) Are there any scars of material significance ?
9 Cardio-vascular System & Blood pressure

a) Does the heart appear to be enlarged ?
If "Yes" do you consider this to be slight, moderate or marked ?
b) Is there any irregularity of rhythm ?
c) Is there any abnormality in the arterial pulse ?
d) Are there any varicose veins ?
e) Blood Pressure : (please record opposite) Systolic / Diastolic mmHg Pulse Rate: 91
10 Respiratory System
a) Is there any abnormality in the shape and development of
the chest ?
b) Are there any abnormal physical signs in the lungs ?
11 Genito / urinary & Digestive System

a) Is the urine test abnormal ?
b) Is there any abnormal tenderness, enlargement or other

palpable abnormality in abdomen ?
c) Is a hernia present
12 Nervous System
a) Is there any sign of disease in the central nervous system ?
b) Is there anything to suggest a tendency to psychiatric

disorder ?
13 Sense Organs
a) Is there any affection of the eyes, ears, nose or tongue Myopia Astigmatisme ODS
Vision Far Vision Near Vision Color Vision

Uncorrected OD - OS - OD - J OS - Adequate
Corrected OD - OS - OD - OS - Defective
Remark :

Telp (0777)7367085, 7367176
5 . EXAMINATION RESULT AND REPORT

X-Ray, ECG, Audiogram and Blood Urine Laboratory Examination Report
All examination result are to be attached. Please, indicate your remark in case of abnormal result
1 Chest X-Ray Report :
2 Spirometry Report :
3 Audiogram Report :
4 Blood Examination Report (Please, attach the result of the following examinations or indicate here below the result) :
1) Heamoglobin 9) Basophils 17) Blood Urea
2) RBC 10) MCV (**) 18) Cholesterol
3) ESR 11) MCM (**) 19) Total Bilirubine
4) WBC 12) MCHC (**) 20) Direct Bilirubine
5) Neutrophils 13) Platelet 21) Alkaline Phosphatase
6) Lymphocytes 14) Reticulocyte (**) 22) AST (SGOT)
7) Monocytes 15) Hematocrit 23) ALT (SGPT)
8) Eosinophils 16) Glycemia 24) Gamma GT
Laboratory findings --->
5 Urine Examination Report :
6 Drugs, alcohol screening test report :
7 HIV Test
8 HbsAg
9 HbsAb
10 TPHA
11 Stool examination
12 Pharyngeal plug test (**)
(**) Only if required

6. OVERALL SUMMARY, ASSESSMENT AND RECOMMENDATIONS
The present Medical Certificate is valid until : and found him (tick the box)
I have examined Of
FIT for duty UNFIT for duty Pending
Examining Doctor's Signature

( Stamp, Signature, Name and address of the Physician ) Date :

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Jl.

Canggai Putri, Teluk Uma

Date: Full Name : Date of birth: Company: Occupation:

Date: Full Name : Date of birth: Company: Occupation:

Name in full Date of birth Sex

Occupation Badge No. Blood Group Rh

Please tick box Yes No Detail if "yes"

b) Asthma, bronchitis, pneumonia or any other lung disorder ?

c) Rheumatism, rheumatic fever, arthritis or any other disorder

g) Any injury, operation, physical defect or deformity ?

h) Any other illness not mentioned above ?

3 a) Have you ever been a patient at a hospital, nursing home

4 Have you ever had any form of sexually transmitted disease `

2 . FAMILY MEDICAL HISTORY

(to be signed in the presence of Medical Examiner)

3 . SUMMARY OF MEDICAL HISTORY OF

2 Nose, mouth or throat trouble 9 Hernia / Hydrocele / Piles / Fissures

3 Color blindness / Loss Vision 10 Fistula / Appendicitis / Varicocele

4 Frequent headaches / Fainting 11 Malaria / Tropical Disease

5 Epilepsy / Mental illness 12 Skin disease

6 Hypertension 13 Cance or tumor

7 Diabetes mellitus 14 Allergy to foods / drugs

4 . MEDICAL EXAMINER'S REPORT

Please tick box Yes No Detail if "yes"

b) Please describe general appearance and build : BMI = Weist :

c) Are there any signs of past or present over-indulgence

e) Are there any scars of material significance ?

9 Cardio-vascular System & Blood pressure

c) Is there any abnormality in the arterial pulse ?

d) Are there any varicose veins ?

11 Genito / urinary & Digestive System

b) Is there any abnormal tenderness, enlargement or other

b) Is there anything to suggest a tendency to psychiatric

Vision Far Vision Near Vision Color Vision

MEDICAL REPORT Jl. Canggai Putri, Tl.Uma, Karimun

5 . EXAMINATION RESULT AND REPORT

5 Urine Examination Report :

6 Drugs, alcohol screening test report :

12 Pharyngeal plug test (**)

(**) Only if required

Examining Doctor's Signature

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