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Medical Examination Report (Aidil Fit)
Medical Examination Report (Aidil Fit)
I here by permit and 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
BLOOD BODY BUILT
HEIGHT WEIGHT PRESSURE PULSE
Reguler Poorty Developed Well Developed Obese
172 60 100/80 72 x Fairy Developed Overweight
Cm kg mmHg /min Yes No
VISION COLOR PERCEPTION (ISHIHARA’S HEARING NOTES / COMMENTS :
METHOD)
Without With Normal
Glasses Glasses Colorblindness YES NO
NONE
Yes
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
Kidney Function Within Normal Limit
Uric Acid Not Checked
Stool Not Checked
ADDITIONAL EXAMINATION
HbsAg Non Reactive
COMMENT ON MEDICAL HISTORY AND CLINICAL EVALUATION
HEALTH CERTIFICATE
No. 159836 / RMC / SKBS / IX / 2011
Issued at Makassar