MEDICAL EXAMINATION REPORT

DATE OF EXAMINATION JANUARY 1st, 2011

COMPANY PRIVATE
NAME OF THE APPLICANT MR. ARIF URSUL M F
PLACE / DATE OF BIRTH BALABTU, January 5th, 1977 Nationality : INDONESIAN
EXAMINATION FOR DUTY AS A A/B Vessel Name : -
MAILING ADDRESS OF APPLICANT BTP Jl. Keruk Raya Tamalanrea PASSPORT No.
Makassar

PHONE NO. -

MEDICAL HISTORY ( Check if any medical conditions listed apply )

YES NO YES NO YES NO YES NO
1. Measles 9. Shortness of Breath 17. Peptic Ulcer 25. Surgical History
2. Diptheria 10. Small Pox 18. Chest Pain 26. Narcotic History
3. Typhoid Fever 11. Ear Disturbance 19. Tuberculosis 27. Alcohol History
4. Liver Disease 12. Nerve Disturbance 20. Kidney Disease 28. Smoking Habit
5. Asthma 13. Thyroid DIsturbance 21. Veneral Disease 29. Hypertension
6. Bronchitis 14. Frequent Headaches 22. Diabetic 30. Loss of Vision
7. Tuberculosis 15. Heart Difficulties 23. Rheumatism 31. Loss of Memory
8. Malaria 16. Fracture 24. Tumor 32. Hernia

33. Have you ever been hospitalized ?

34. Have you ever been declared unfit for sea duty ?
35. Do you feel healthy and fit to perform the duties of your designated ?
36. Are you on medication ?
37. Are you allergic to any specific food, drugs, or other conditions such as weather ? (if yes give detail)

I here by permit by Shipping Company/Agency/Manning Agency and the undersigned physician to funish such information the company may need
pertaining to my health status and other pertinent and medical finding and do here by release them from any and all legal responsibility by doing so.
I also certify that my medical history above is true and any false statement will disqualify me from employment benefits and claims.

_______________________
Signature of Examinee

PHYSICAL EXAMINATION
HEIGHT WEIGHT BLOOD PULSE BODY BUILT
PRESSURE
Reguler Poorty Developed Well Developed Obese
157 53 100/70 80 x Fairy Developed Overweight
Cm kg mmHg /min Yes No
VISION COLOR PERCEPTION (ISHIHARA’S METHOD) HEARING NOTES / COMMENTS :
Without With Normal
Glasse Glasses Colorblindness Yes YES NO NONE
Right Eye 20 / 20 - (If yes give detail) Right Ear
Left Eye 20 / 20 - Left Ear
No
Both Eye 20 / 20 -
Normal Normal Normal
YES YES NO YES NO
NO
1. Eyes 8. Lungs 15. Skin & Nails
2. Ears 9. Heart 16. Speech
3. Nose 10. Urogenal System 17. Hernia
4. Mouth 11. Upper Extremities 18. Abdomen
5. Throat 12. Lower Extremities 19. Scarr
6. Thyroid 13. Back Abnormality 20. Reflexes
7. Lymp Node 14. Central Nervous System 21. Other
 CHEST X-RAY REPORT
Within Normal Limit
ELECTROCARDIOGRAPHY
Within Normal Limit
LABORATORY FINDINGS
Hematology Within Normal Limit
Urinelisis Within Normal Limit
Glucosa Metabolism Within Normal Limit
Fat Metabolism Not Checked
Lever Function Within Normal Limit
Kidneys Function Within Normal Limit
Uric Acid Not Checked
Stool Not Checked
ADDITIONAL EXAMINATION
VDRL Negatif
Drugs and Alcohol Negatif
COMMENT ON MEDICAL HISTORY AND CLINICAL EVALUATION

The above named person physically FIT for duties on board ship

HEALTH CERTIFICATE
No. 142042 / RMC / SKBS / I / 2011

THIS IS TO CERTIFY THAT A MEDICAL EXAMINATION WAS GIVEN TO :

Mr. ARIF URSUL Age : 34 Years
HE IS FOUND TO BE FIT FOR DUTY AS : A / B

Issued at Makassar

Date : January 28th, 2011 dr. FIKA ANGELINA HALIEM

Examining Physician