DOLE/BWC/HSD/OH-47-A

Republic of the Philippines

DEPARTMENT OFLABOR AND EMPLOYMENT
National Capital Region
ANNUAL MEDICAL REPORT FORM
For Period January 1, 2015 to December 31, 2015
1. Name of Establishment: ___MARYSVILLE BOARDING HOUSE_____________________________
2. Address: __________1452 SH Loyola St., Sampaloc, 045 Bgy 457, Manila______________________
3. Name of Owner/Manager: ________Anita F. Carbonel______________________________________
4. Nature of Business and Production/Service (Ex. Manufacturing Textile): ____________________
____________________Dormitory / Boarding House_______________________________________
5. Total Number of Employees: _______4__________ Number of Shifts: _____1________________
6. Number Distribution of Employees as to nature/workplace, sex and workshift:
Office
Production/Shop
1st Shift
Male : ___1______
Female: ___3______
Total : ___4______

____1_____
____3_____
____4_____

2nd Shift
__________
__________
__________

3rd Shift
__________
__________
__________

7. Preventive Occupational Health Services: (Check or Cross)

a. Occupational health services is organized/provided by:
( )
the establishment/undertaking
( )
government authority/institution
( )
other bodies/groups/institution (specify) _____________________________________
_____________________________________________________________________
b. Occupational health services as described under number 7a above, is organized/provided as a
Service:
( )
solely for the workers of the establishment/undertaking
( )
common to a number of establishments/undertakings ___________________________
______________________________________________________________________
c.

The employer engages the services of:

( )
Occupational Health Practitioner
Name
: _________________________________________________________
Address
: _________________________________________________________
( )
Occupational health physician
Name
: _________________________________________________________
Address
: _________________________________________________________
( )
Occupational health dentist
Name
: _________________________________________________________
Address
: _________________________________________________________
( )
Occupational health nurse
Name
: _________________________________________________________
Address
: _________________________________________________________

d. The occupational health physician/practitioner/nurse/personnel conducts an inspection of the

workplace:
( )
once every month
( )
once every three (3) months
( )
once every two (2) months
( )
once every six (6) months
( )
other details ____________________________________________________________

8. Emergency Occupational Health Services:

a. The employer provides a treatment room/medical clinic in the workplace with medicines and
facilities:
( )
yes
( )
no
( )
others, please specify _____________________________________________________
_______________________________________________________________________
b. Schedule of attendance in the workplace:
Work shift
Occupational health physician
Occupational health dentist
Occupational health practitioner
Occupational health nurse
c.

: ________________ hrs./day _____________

: ________________ hrs./day _____________
: ________________ hrs./day _____________
: ________________ hrs./day _____________

Schedule of attendance of full time first aider:

( )
1st work shift
( )
2nd work shift
( )
3rd work shift

d. The following occupational health personnel of the establishment have undergone training in
occupational health and safety/first aid:
( )
occupational health physician
( )
occupational health dentist
( )
occupational health nurse
( )
first aider
( )
others, please specify _____________________________________________________
_______________________________________________________________________
9. Occupational Health Services:
a. The occupational health personnel of this establishment conducts regular appraisal of the
sanitation system in the workplace::
( )
yes
( )
no
b. Number of workers who underwent the following medical examination:
Physical Exam
X-Rays
Urinalysis
1. Pre-placement
______________
_____________
________________
2. Periodic
______________
_____________
________________
3. Return-to-work
______________
_____________
________________
4. Transfer
______________
_____________
________________
5. Special
______________
_____________
________________
6 Separation
______________
_____________
________________
1.
2.
3.
4.
5.
6.

Pre-placement
Periodic
Return-to-work
Transfer
Special
Separation

Stool Exam
__________
__________
__________
__________
__________
__________

Blood Test
__________
__________
__________
__________
__________
__________

ECG
________
________
________
________
________
________

Others
__________
__________
__________
__________
__________
__________

10. Report of Diseases:

a. Number of consultations/treatments for the following diseases:
Male

Female

Total Number
of Cases

Skin:
(
(
(

)
)
)

_______
_______

_______
_______

___________
___________

allergy
dermatoses
infection as folliculitis
abscess/paro nychia
Others

_______
_______

_______
_______

___________
___________

(
(

)
)

tension headache
Others

_______
_______

_______
_______

___________
___________

(
(

)
)

error of refraction
bacterial/viral
conjunctivities
cataract
Others

_______

_______

___________

_______
_______
_______

_______
_______
_______

___________
___________
___________

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___________
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___________

Head:
Eyes:

( )
( )
Mouth & ENT:
( )
Gingivitis
( )
Herpes labiales/nasalis
( )
Otitis Media/Externa
( )
Deafness
( )
Menleres Syndrome/Vertigo
( )
Rhinitis/Colds
( )
Nasal Polyps
( )
Sinusitis
( )
Tonsillopharyngitis
( )
Laryngitis
( )
Others
Respiratory:
( )
Bronchitis
( )
Bronchial asthma
( )
Pneumonia
( )
Tuberculosis
( )
Pneumoconiosis
( )
Others
Heart and Blood Vessel:
( )
Hypertension
( )
Hypotension
( )
Angina Pectoria
( )
Myocardial Infraction
( )
Vascular disturbances in
extremeties due to
continuous vibration
( )
Others
Gastrointestinal:
( )
gastroenteritis/darrhea
( )
amoebiasis
( )
gastritis/hyperacidity
( )
appendicitis
( )
infectious hepatitis
( )
liver cirrhosis
( )
hepatic abscess
( )
cancer (hepatic/gastric)
( )
ulcer
( )
Others

Genito Urinary:
( )
Urinary tract infection
( )
Stones
( )
Cancer
( )
Others
Reproductive:
( )
Dysmenorrhea
( )
Infection (Cervicitis)
(vaginitis)
( )
Abortion (Spontaneous)
(Threatened)
( )
Hyperemesis Gravidarium
( )
Uterine Tumors
( )
Cervical Polyp/Cancer
( )
Ovarian Cyst/Tumors
( )
Sexually-Transmitted
diseases
( )
Hernia (Inguinal)
(Femoral)
( )
Others
Neuromuscular/Skeletal/Joints:
( )
Peripheral Neuritis
( )
Torticollis
( )
Arthritis
( )
Others
Lymphatics and Circulatory:
( )
Anemia
( )
Leukemia
( )
Cerebrovascular Accidents
( )
Lymphadenitis
___________
( )
Lymphoma
Infectious Diseases:
( )
Influenza
( )
Typhoid/paratyphoid fever
( )
Cholera
( )
Measles
( )
tetanus
( )
Malaria
( )
Schistosomiasis
( )
Herpes Zoster
( )
Chicken Pox
( )
German Measles
( )
Rabies
( )
Others
Diseases due to Physical Environment:
a)
Diseases due to Noise and vibration
( )
Deafness (noise induced)
( )
White fingers disease
( )
Musculo-skeletal
disturbances
( )
Fatigue

Male

Female

Total Number
Of Cases

_______
_______
_______
_______

_______
_______
_______
_______

___________
___________
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_______
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___________
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___________
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___________

_______
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_______
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___________
___________

_______
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_______
_______

___________
___________

b)

c)

d)

Diseases due to Temperature

And Humidity abnormalities:
Hot Temperature:
( )
heat strokes
( )
heat cramps
( )
dehydration
( )
heat exhaustion
( )
others
Cold Temperature:
( )
Chilblain
( )
frost bite
( )
immersion foot
( )
general hypothemia
( )
others
Diseases due to Pressure
Abnormalities:
( )
Decompression Sickness:
( )
air emboism
( )
bends disease
( )
barotrauma
( )
hypoxia
( )
altitude sickness

Diseases due to radiation:

( )
cataracts
( )
keratitis
( )
burns
( )
radiation-related cancers
TOTAL NUMBER

11. Report of Occupational Accidents/Injuries:

Nature
Contussion, bruises, hematoma
Abrasions
Cuts, lacerations, punctures
Concussion
Avulsion
Amputation, loss of body parts
Crushing Injuries
Spinal injuries
Cranial Injuries
Sprains
Dislocation/Fractures
Burns
12.

Immunization Program
(Indicate number immunized)
Tetanus Toxoid Injection
Tetanus Antitoxin Injection
Tetanus Globulin Injection
Hepatitis B Vaccine
Rabies Vaccine
Others (Please specify)

_______
_______
_______
_______
_______

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___________
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_______
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___________
___________
___________
___________
___________

Male

Female

Total Number
of Cases

_______
_______
_______
_______
_______

_______
_______
_______
_______
_______

___________
___________
___________
___________
___________

Male

Female

_______
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_______
_______
_______

_______
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_______
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_______
_______
_______

Number of
Cases
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________

Male

Female

Total

_______
_______
___________
_______
_______
___________
_______
_______
___________
_______
_______
___________
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_______
___________
_______
_______
___________

13. Keeping of Medical records of Workers (Please check)

( )
done
( )

not done

14. Health Education and Counselling by Health and Safety Personnel: (Please check one ormore)
(
(
(

)
)
)

done individually as each worker comes to the clinic for consultation.

done in organized group discussions/seminars.
done with the use of visual displays and/or promotional materials, leaflets, etc.

15. Other Health Programs: (Please check)

Kinds of Program

Seminar

Use of Visual
Aid/Materials

Counselling

Nutrition Program
Maternal and Child Care Program
Family Planning Program
Mental Health Activities
Personal Health Maintenance
Physical fitness Program: (Please check)
Sports Activities
Others (Please specify)

(
(

)
)

Yes
Yes

(
(

)
)

No
No

16. Hazards in the workplace: (Please check and give details of the substance)

a) Chemical Hazards:
( )
dust (Ex. Silica dust)
( )
liquids (Ex. Mercury)
( )
mist/fumes/vapors (Ex. Mist
from paint spraying)
( )
gas (Ex. CO, H2S)
( )
others (please specify)
(Ex. Solvents)
b)

c)

Physical Hazards:
( )
noise
( )
temperature/humidity
( )
pressure
( )
illumination
( )
radiation/ultraviolet/
microwave
( )
vibration
( )
Others (Please specify)
Biological Hazards:
( )
Viral
( )
Bacterial
( )
Fungal
( )
Parasitic
( )
Others

Substances and/or
Sources

Number of workers
exposed

________________
________________

________________
________________

________________
________________

________________
________________

________________

________________

________________
________________
________________
________________

________________
________________
________________
________________

________________
________________
________________

________________
________________
________________

________________
________________
________________
________________
________________

________________
________________
________________
________________
________________

d)

Ergonomic Stress:
( )
Exhausting physical work
( )
Prolonged standing
( )
Excessive mental effort
( )
Unfavorable work posture
( )
Static/monotonous work
( )
Others, specify

________________
________________
________________
________________
________________
________________

________________
________________
________________
________________
________________
________________

Submitted by:
_______________________________
Medical Personnel/Title

___________________
Date
Noted by:
______Anita F. Carbonel___________
Employer