MEDICAL CHECK UP (MCU)

PUSKESMAS BANGSRI 1

I. Personal Details
First Name : ID Number :
Last Name : Badge number :
Date of Birth : Company Name : II.
Gender : □ Male □ Female Job Title :
Marital Status : □ Single □ Married Date of hire : P
Home Address : MCU Provider :
Telephone : Date of MCU :
Email Address : Doctor Name :
Nationality : Type of MCU :
resent Job Details

Job Title: Job Number : Department :

Present Exposure Code Present Exposure Code

□ Chemical,Not otherwise Specified (NOS) 320.06 □ Posture, Body-Dynamic 362.03
□ Solvent,Not Otherwise Specified (NOS) 171.00 □ Ergonomic Factors, NOS 360.00
□ Carbon Black 010.04 □ Forceful Movement, NOS 361.01
□ Hydrogen Sulfide 040.06 □ Operating light vehicle
□ Inks 170.02 □ Keyboard Use 360.02
□ Carbonless Paper 320.05 □ Lifting 361.02
□ Formaldehyde 120.03 □ Vibration, NOS 354.00
□ 1,1,2-Trichloroethane 190.12 □ Vibration, Whole body 354.02
□ Hydrocarbons,Not Otherwise Specified 170.00 □ Hunidity, Hight 350.05
(NOS)
□ Plant Material, Not Otherwise Specified 370.00 □ Posture, Upper Extremity 362.01
(NOS)
□ Smoke, NOS 330.03 □ Infectious Agent 390.07
□ Cigarette Smoke 330.01 □ Waste, Hazardous 323.01
□ Vegetable Dust 370.04 □ Waste, NOS 323.00
□ Dust, NOS 010.12 □ Venom 380.05
□ Pollen 370.10 □ Insect Bite, NOS 382.21
□ Silica, Amorphous 010.12 □ Mosquito Bite 382.21
□ Silica, Crystalline 010.13 □ Fall, NOS 353.03
□ Heat 350.03 □ Stress 360.04
□ Operating Heavy Equipment □ Noise 350.01
□ Radiation, Ultraviolet 352.04 □ Natural Gas 060.08
□ Radioactive exposure □ Hypoxia 353.04
□ Food Handling □ Biological Risk
□ Poisonous Plants 370.06 □ Pesticide use
□ Other:

III. Occupational History

Past Job Company Periode of Working Past Exposure Code
1.
2.
3.
1.
2.
3.

IV. Medical History

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 MEDICAL CHECK UP (MCU)
PUSKESMAS BANGSRI 1
Have you suffered from any of these in the past
Y/N
Aches, Pain, Fever
Allergic Rhinitis/Hay Fever
Anemia
Asthma/Allergic Asthma
Athlete Foot (Ring Worm)
Atopic Dermatitis (Eczema)
Blood Pressure Problem
Bronchitis, Chronic (COPD)
Cancer
Carries/Dental Cavities
Chest Pain/Heart diseases
Chronic skin problem
Chronic cough
Chronic diarrhea > 2weeks
Diabetes
Ear/hearing problem
Eye Allergic/conjunctivitis
Epilepsy
Fainting, blackouts
Hemorrhoids
Headache/Migraine
Please explain the
above positive
findings
Other Medical
History
Regular Medication
V. Family History
VI. Allergic History
Y/N
Head injury or concussion
Hepatitis/Jaundice
High Cholesterol
High Uric Acid
Kidney problem disease
Low Back Pain >4weeks
Malaria/tropical disease
Psychiatric disorder
Sexually Transmitted Disease
Surgery/operation
Typhoid Fever
Urinary Tract Infection
Visual Problem
Significant weight Loss/Weight gain
Abortion (miscarriage)
Birth Control (contraceptive)
Breast Feeding
Menstrual Cramps/Dysmenorrhea
Obstetric or gyn problem
Pregnancy
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PUSKESMAS BANGSRI 1

Y/N Y/N

VII. Vaccination History

Please Fill Vaccination Date
MMR Measles Rubella Mumps HepA HepB Varicella Meningococcal Influenza Polio Typhoid BCG

Others

VIII. Life Style

Smoking Alcohol consumption
□ None □ None
□ Quit more than five years □ Drinker:……..unit/week
□ Recently quit Note: 1 unit is equivqlent to: 1 can/bottle of
Smoker:…….pcs/day for……..years beer, 1 glass of wine or 1 shot of liquor
□

I certify that the above statements are to the best of my knowledge and belief correct. I
consent to the result of this examination being store in paper or electronic format. I am willing
that if required the work related medical information may be released to company
management.

Signature of Witness Date Employee Signature Date

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PUSKESMAS BANGSRI 1

Blood Pressure Pulse Respiratory Body

Pulse rhythm Body Body
(mmHg) Rate Rate Temperature BMI
Height Weight
Systolic Diastolic (bpm) Normal Abnormal (bpm) (oC)

JVP Apex Beat Heart Sound Murmurs

Normal Abnormal Normal Abnormal Normal Abnormal No Yes

Comments:

X. Physical Examination
Without spectacles With owned spectacles Color Vision:
Vision
Acuity Distance Near Distance Near □Normal□Red/GreenDef□Total color
Blind
Right Visual field
Left □Normal □Abnormal
Both
Comments :

If abnormal, please explain abnormal findings

Head & Neck □ Normal □ Abnormal

Ear □ Normal □ Abnormal

Nose □ Normal □ Abnormal

Throat □ Normal □ Abnormal

Dental □ Normal □ Abnormal

Eye □ Normal □ Abnormal

Cardiovascular □ Normal □ Abnormal

Breast □ Normal □ Abnormal

Chest & Lung □ Normal □ Abnormal

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PUSKESMAS BANGSRI 1

Abdomen □ Normal □ Abnormal

Genito Urinary □ Normal □ Abnormal

Extremities & Back

Upper and Lower □ Normal □ Abnormal

Examination of
Female Pelvic □ Normal □ Abnormal

Rectal □ Normal □ Abnormal

Skin □ Normal □ Abnormal

Lymph Nodes □ Normal □ Abnormal

Identifying Marks □ Normal □ Abnormal

Musculosceletal an Neurological
Lumbar Spine Examination
Scoliosis□No □Yes Forward Flexion 0o 80o □No □Yes Heel Walking □Normal □Abnormal
Kyphosis □No □Yes Hyperextension 0 25o o
□No □Yes Toe walking □Normal □Abnormal
Lordosis □No □Yes Lateral Flexion 0o 20o □No □Yes Squats 3x □Normal □Abnormal
General Musculoskeletal □Normal □Abnormal
Reflexes :
Biceps □N □A Triceps □N □A Patella □N □A Achilles □N □A Plantar Response □N □A

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PUSKESMAS BANGSRI 1

Investigation Audiometry : Result attached

Electrocardiography : Result attached Left Ear Right Ear
Q – Waves
□ Positive □ Negative 500 Hz dB 500 Hz dB
BBB 1000 Hz dB 1000 Hz dB
□ Positive □ Negative 2000 Hz dB 2000 Hz dB
Minor Abnormality
□ Positive □ Negative 3000 Hz dB 3000 Hz dB
LVH with Strain 4000 Hz dB 4000 Hz dB
□ Positive □ Negative 6000 Hz dB 6000 Hz dB
ST Depression
□ Positive □ Negative 8000 Hz dB 8000 Hz dB
Atrial Fibrilation Comments :
□ Positive □ Negative
Major Abnormality
□ Positive □ Negative
Comments :

Chest X-Ray : Result attached Spirometry : Result attached

Measured Predictive % Predictive
Result Value
FVC L
FEV1 L
FEV1/FVC %
FEV1% %
PEF L/s
PEF 50 L/s
PEF 75 L/s
FEF 25-75 L/s
Mark Findings on Lung Refers to Examination or X-ray
result FET s
Comments: Comments:
Pneumoconiosis : No Yes
Cardiac size :□Normal □Abnormal

Name Male/Female COMPANY/Badge No

Age FILE NO.
Doctor’s Name DATE

HEMATOLOGY
Diff Count

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□ Hb g/dl □ Neutrophil %
□ WBC K/UL
□ Lymphocyte %
□ Erytrocyte /μL
□ Trombocyte /mm3 □ Monocyte %
□ Hematocrite %
□ Eosinophil %
□ Sed Rate/LED mm/h
□ MCV fL □ Basophil %
□ MCH Pg
□ MCHC g/dL
□ Blood Group
□ Rhesus
BIOCHEMISTRY
Liver Function Test Serology Renal Function Test
□ SGOT IU/L Hbs Ag : □ Ureum mg%
□ SGPT IU/L Anti HBS : □ Creatinin mg%
□ Gamma GT IU/L VDRL : □ Uric Acid mg%
HIV :
Lipid Profile Test Anti HCV : Diabetes
□ Total Cholesterol mg% Paracyte □ Glucose Fasting mg/dL
□ Triglyseride mg%

Routine Urine Analysis Microscopic Routine Stool Analysis (Catering Crew)

Macroscopic WBC Macroscopic
Color RBC Colour
Turbidity Crystal Consistency
Spec.gravity Bacteria
PH Epithel Microscopic
WBC Urine Cylinder WBC
Ketones Other RBC
Glucose
Urobilinogen
Protein
Bilirubin
Blood
Nitrite
Lab Technician: Date : Doctor :

Comments :

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 MEDICAL CHECK UP (MCU)
PUSKESMAS BANGSRI 1

CERTIFICATE
OF
MEDICAL FITNESS

FOR MANAGEMENT

Name File / Badge Number Occupation

Department Supervisor Manager

Requires Colour Blood Respiratory Defect Impaired Hearing Vertigo

Spectacles Blindness Group
 Yes  No  Yes  No  Yes  No  Yes  No  Yes  No

 Fit The candidate are considered fit for the designated jobs, i.e. they are capable of doing their jobs without any
restrictions.

 Currently Fit The candidates are considered to be fit for the designated jobs. Although they suffer from low or moderate health
risks, these risks are under control by the medical doctor on site.

 Currently The candidates are temporarily unfit for their designated jobs because:
Unfit  The candidate has a medical defect that limits his or her fitness to perform the designated job or having
medical condition that would create health hazards to him or herself and to others or other whereby the
medical condition cannot be controlled. He or she is currently unfit until refer for treatment and whenever he
or she is cured or corrected, he or she might be fit to perform the designated job
 The candidate have severe health risks that significantly increase the probability of having to be medical
evacuation (Medevac)
 The candidate has contracted a communicable disease.

The candidates are permanently unfit for their designated jobs because:
 Unfit  The candidate cannot perform their tasks and/or they might endanger either their own health and safety or the
health and safety of others. The candidate is not fit and healthy to perform the designated job.
He or she might be acceptable for another job that has different physical demands

Examining Doctor Signature Date

A change of occupation may render this certificate invalid

Recertification should be obtained from the medical officer