PRE EMPLOYMENT

MEDICAL EXAMINATION FORM

FOR ANEKA PURA PERSONNEL

Part I Untuk dilengkapi oleh Karyawan

PERSONAL DETAILS
Nama :

Panggilan:

Alamat:

Status Pernikahan:

Tanggal lahir:

Posisi:

Tempat Lahir:

Gender:

SOCIAL / OCCUPATIONAL HISTORY

1. Do you smoke? If so how many per day

2. If an ex-smoker, when did you give it up?
3. Average weekly alcohol consumption: state quantity and type
4.

Have you been exposed to any known occupational hazard

such as noise, radiation, dust, asbestos, chemicals or lead?

5. Have you used protective clothing, safety glasses or hearing

protection?
6.

Have you ever developed any medical condition in connection

with your occupation? If so please give details e.g. Hearing
loss/skin condition /wheeze/backache/muscle strain/blood
disease?

7. Have you suffered any industrial injury?

If so please give details.
8. Have you had any previous audiometric screening?
Was this normal? State when and where?
9. Have you had previous lung function screening?
Was this normal?
State when and where?
10. Do you have any disabilities?
Use a separate sheet if required
11. Have you ever been rejected from employment or insurance on
medical grounds?
12. Have you received compensation for an industrial claim /or is

there any industrial claim pending?

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CONFIDENTIAL WHEN COMPLETED

13. Have you ever been medivaced from an offshore installation?

Give dates and details:
14. Have you been hospitalised in the last five years? If yes please
provide details?':

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CONFIDENTIAL WHEN COMPLETED

Nama Karyawan ::
MEDICAL HISTORY REQUIRING SPECIAL CONSIDERATION
DO YOU HAVE OR HAVE BEEN DIAGNOSED AS SUFFERING FROM ANY OF THE FOLL0WING:
Please include any family history of the following in addition
Please Elaborate
YES
NO

1. Chest pain / heart disease

YES
NO

2. High blood pressure / stroke

YES
NO

3. Asthma / epilepsy / diabetes

YES
NO

4. Peptic ulcer disease

YES
NO

5. Kidney disease (eg. Stones )

6. Psychiatric disorder eg. anxiety,

YES
Depression
YES
7. Tuberculosis
YES
8. Cancer
9. Have you or anyone in your family an
YES
existing medical condition?
10. Vaccination history: Poliomyelitis Tetanus
Approx. Date:

NO

NO
NO

NO

Hep. A

Hep. B

BCG

Meningitis

DECLARATION
MOHON BACA PERNYATAAN BERIKUT DAN JIKA SETUJU, AGAR TANDATANGANI DAN
BERI TANGGAL
Saya Menyatakan bahwa data diatas adalah benar . Saya setuju bahwa hasil dari medical check up
berdasarkan pengujian yang dilakukan sudah sesuai berhubungan dengan kesehatan saya yang digunakan
hanya untuk kepentingan kesehatan perusahaan. Saya menyetujui bahwa PT ANEKA PURA dapat
dipercaya untuk kondisi kesehatan saya sendiri sebagaimana tertera dalam laporan medical check up.

TANDATANGAN KARYAWAN:
TANGGAL:

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CONFIDENTIAL WHEN COMPLETED

Part II Dilengkapi oleh Dokter:

DO YOU HAVE OR HAVE YOU HAD ANY SIGNIFICANT OR RECURRENT PROBLEMS WITH THE FOLLOWING?
Please Elaborate

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.

Backache / joint or muscular pain

YES
Hernia / rupture
YES
Visual impairment
YES
Perforated eardrum / discharge from ear
YES
Recurrent indigestion
YES
Jaundice / hepatitis / gall bladder disease
YES
Changes in bowel habit / diarrhea
YES
Blood in stool / piles, hemorrhoids
YES
Shortness of breath /coughing up blood
YES
Recurrent bronchitis / pneumonia
YES
Blood in urine / kidney complications
YES
Headaches / migraine / dizziness
YES
Varicose veins
YES
Skin trouble (e.g. dermatitis / eczema)
YES
Surgical operations
YES
Hospitalization
YES
Fear of flying / fear of heights
YES
Tropical disease / venereal disease
YES
History of alcohol / drug abuse
YES
Do you have any allergies? Please list.
YES
Do you have any current illnesses? Please list.
YES
Are you receiving any medication at present?
YES
Please list.
23. Have you attended a dentist in the last year?
YES
24. Are you undergoing dental treatment?
YES
25. Date of last tetanus booster.
YES
FOR FEMALES ONLY HAVE YOU EVER HAD?
26. Abnormal smear / breast disease.
YES
27. Gynecological problems e.g. pelvic infection.
YES
28. Complications of pregnancy.
YES
29. Please give date of last menstrual period.
YES

NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO

NO
NO
NO

NO
NO
NO
NO

EXAMINING PHYSICIANS COMMENTS

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CONFIDENTIAL WHEN COMPLETED

TO BE COMPLETED BY EXAMINING DOCTOR

HEIGHT

WEIGHT

BMI

BP

PULSE

PEAKFLOW

VISION - DISTANCE

VISION - NEAR

AIDED L

AIDED R

BOTH

BOTH

AIDED L

AIDED R

URINALYSIS

PREDICATED
PFR

PROTEIN

BLOOD

GLUCOSE

COLOUR VISION
ISHIHARA TEST
NORMAL
ABNORMAL

ELABORATE ON ABNORMAL FINDINGS

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

EYES/PUPILS
EAR, NOSE & THROAT
TEETH & MOUTH
LUNGS / CHEST
CARDIOVASCULAR
ABDOMEN
HERNIAL ORIFICES
RECTAL
GENITOUTINARY & TESTES
MUSCULOSKELTAL
SKIN
VARICOSE VEINS
NEUROLOGICAL
BREASTS
IDENTIFYING MARKS
(E.G. TATTOOS/SCARS ETC.)

INVESTIGATIONS
BLOOD HB / THICK FILM FOR
MALARIA, MICROFILARIA
VDRL/RPR
HIV
HBs Ag.
ANTI. HCV
U&E, LFTs
CHEST X-RAY
AUDIOMETRIC SCREENING
ECG
STOOL CULTURE
(CATERING STAFF)
OTHER
KESIMPULAN

SEHAT/TIDAK SEHAT untuk bekerja (*)

TANGGAL
Paraf:__________________________Nama Dokter

SETUJU BAHWA KARYAWAN SEHAT

UNTUK BEKERJA

Dr. ISTIFA AMALIA

PUSKESMAS SUBAN

Date :

SETUJU BAHWA KARYAWAN

TIDAK SEHAT UNTUK BEKERJA

Date :

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CONFIDENTIAL WHEN COMPLETED