Nama : ………………………………………………………………..

Name

Perusahaan : ………………………………………………………………..
Company

Tanggal : ………………………………………………………………..
Date

RAHASIA MEDIS
MEDICAL CONFIDENTIAL
Reg. No :

Date :

Subject :

Dear Mr/Mrs …………………………………………..

Thank you for attending our center.

Enclosed is the result of your medical examination performed on …………………..., 20… the
medical history shows that no diseases or health risk factors were found. At the date of
examination you felt healthy.

The following is summary of your medical examination result :

1. Date of birth :
2. Height : cm
3. Body weight : kg
4. Pulse : x/minute
5. Blood pressure : A. Sitting : mmHg
B. Supine : mmHg
6. Physical examination :
7. Eyes examination :
8. E.N.T examination :
9. Audiogram :
10. X-Ray chest :
11. E.C.G resting :
12. Laboratory findings :
 SUMMARY FINDINGS AND SUGGESTION

Regard

Regard

dr.
 PATIENT’S DATA

REGISTER NO. :
NAME :

EXAMINATION DATE :

DATE OF BIRTH :

SEX :

MARITAL STATUS :

RELIGION :

NATIONALITY :

POSITION/DEPARTEMENT :

COMPANY NAME :

COMPANY’S ADDRES :

COMPANY’S PHONE :

HOME ADDRES :

HOME TELEPHONE :
 MEDICAL HISTORY

PRESENT STATUS
1. DO YOU FEEL WELL TODAY ? :
2. ARE YOU SUFFERING ANY
DISABILITY/DISEASE AT PRESENT ? :

PAST HISTORY
1. Respiratory disease :
2. Digestive disease :
3. Urinary track disease :
4. Lung disease/TBC/Pneumonia :
5. Diabetes mellitus :
6. Hepatitis / liver :
7. Hypertension :
8. Heart disease :
9. Allergies (food, drug) :
10. Headache :
11. Defect in vision / eyes trouble :
12. Hearing defect :
13. Have you ever been in hospital ? :
14. Have you ever undergone surgery :
15. Sexually transmitted disease :
16. Psychiatric disorder :
17. Food poisoned :
18. Others :

HABITS
19. Smoking :
20. Drink alcohol :
21. Exercise regulary :
22. Others :
MEDICAL EXAMINATION
ANTROPOMETRI
1. Height : cm
2. Weight : kg
3. Blood pressure : mmHg
4. Pulse : x/menit

PHYSICAL DIAGNOSTIC
5. General health :
6. Physical :
7. Eyes :
8. Dental :
9. T.H.T :
10. Neck :
11. Heart :
12. Lungs :
13. Liver :
14. Lien :
15. Back bones :
16. Pelvic :
17. Inguinal :
18. Upper extremitas :
19. Lower extremitas :
20. Pathologic reflex :
21. Phyciologis reflex :

Conclusion :
Advice :
Dokter Pemeriksa

dr.
 HASIL AUDIOGRAM
AUDIOGRAM RESULT

Reg. : …………………………… Tanggal Lahir : …………………………

Date of Birth
Nama : …………………………… Perusahaan : …………………………
Name Company
Jenis Kelamin : …………………………… Tanggal : …………………………
Sex Date

ANSI 1969
STANDARD
125 250 500 750 1000 1500 2000 3000 4000 6000 8000
10 Test Right Eat Leaft Eat
(Red) (Left)
0 AIR O-O X-X
HEARING THRESHOLD LEVEL IN dB

10 AIR - -
20 MASKED
30
NO
RESPONSE
40
BONE < >
50 BONE ┌ ┐
60 MASKED └ ┘
70 HEARING
AVALUATION
80 AVGT/T
90 ST
100 LDL
110
MCL
WD
120

AUDIOMETRY

125 250 500 750 1000 1500 2000 3000 4000 6000 8000

RIGHT EAR :

LEFT EAR :
 PEMERIKSAAN TELINGA (TES BERBISIK)

Standar :
1. Dapat mendengar suara bisikan dari jarak ≥ 1.65 meter dengan atau tanpa alat bantu
dengar (hearing aid) ATAU
2. Rata-rata penurunan pendengaran pada telinga yang terbaik ≤ 40 Db dengan atau tanpa
menggunakan alat bantu dengar.

Menggunakan alat bantu dengar ? : Ya Tidak

Test Berbisik : Telinga Kanan : ……..... meter Telinga Kiri : ……..... meter
Reg. : …………………………… Date of Birth : …………………………

Name : …………………………… Company : …………………………

Sex : …………………………… Date of : …………………………

Examination

EXAMINATION : CHEST

Dear Colleague,

CHEST
Lungs :

Heart :

Sinus & Diaphgram :

Bones :

CONCLUSION :

dr.
Radiologist
 Resume Evaluasi Kelaikan Kerja untuk Karyawan Kontraktor
IDENTITAS KARYAWAN
Nama Tanggal Lahir (hh/bb/thn) Jenis Kelamin Lokasi Kerja

Laki-laki perempuan
Nama Perusahaan FFD Procedure : Onshore
Pre-placement Periodic Return to Work For Cause Offshore

Job Title : Food Handlers Emergency Responder Fire Brigade Drivers Offshor Oil & Gas Workers
Crane Operator Onshore Non-Sedentary Workers Sedentary

REKOMENDASI KELAIKAN KERJA

Laik Kerja, masa berlaku : 3 bulan 6 bulan 1 tahun
Laik Kerja dengan batasan :
1. ……………………………………………………………………………………………………………
2. ……………………………………………………………………………………………………………
3. ……………………………………………………………………………………………………………
4. ……………………………………………………………………………………………………………
Tidak Laik Kerja : Permanen Sementara, dievaluasi setelah ………………….. minggu/bulan
Tidak dapat memenuhi evaluasi yang diminta, dengan alas an ………………………………………………
…………………………………………………………………………………………………………………

Rekomendasi (jika diperlukan tindak lanjut) :……………………………………………………………………..

……………………………………………………………………………………………………………………..
Catatan : Harus menggunakan kaca mata Harus menggunakan alat bantu dengar
Dokter Pemeriksa Tanda Tangan Tanggal (hh/bb/thn)

Nama Provider Alamat & No. Telp :