RUMAH SAKIT KHUSUS BEDAH

KARTIKA DOCTA
Jl. Gajah Mada No.14 – Padang Telp. (0751) 4481278
www.kartikadocta.com email: info@kartikadocta.com

PRE-EMPOYMENT MEDICAL TEST

NAMA : FILE No. :

AGE :
SEX : DATE :
HEMATOLOGY
ESR (Westerdreen) Hemoglobin RBC WBC HBsAG Anti Bhs

20 mm/st hr 12-14/14-15 4-5,5 m/mm cu 5000-10000

Neutrophils Lymphocytes Monocytes Eosinophils Baspphils

50-70 % 20-4-0% 2-8 % 1-3 % 0-1%

BLOOD CHEMISTERY
Total Protein Albumin Globulin Total bilirubin Indirect Bil Direct Bil

6-8 gr% 3,5 – 5,2 gr% 2,5 – 3,5 gr% <1 m gr% <0,75 mg% <0,5 mg%
Tymol Turbidity Alkaliphosphatese SGOT SGPT HDL Cholesterol
Test

0-5 unit 15-69 mu/ml 31-37 unit/L 31-40 unit/L >55-65 mg% 150-250 mg%
Glucose Ureum Creatinine Uricacid LDL Triglyceride

100-120 mg% 20-40 mg% 0,5 – 1,5 mg% 3-5 mg% <150 mg% 0-125 mg%
URINALYSIS
Specific gravity Albumin Sugar Bilirubin Urobilin Ph

1000-1030 (-) (-) (-) (+)

Sediment YBC RBC CAST Crystal HbSAg

1-3 (-) (-) (-)

STOOL For ova and parasites Visual Acuity  With/without glases 
 Negative  Positive R:  N/  A ------------------------------------
L: N/  A ------------------------------------

Chest X-Ray  Normal Chest  Ahnormalities

Ro.No.
Heart
Size :  N/  A/
Thrill :  N/  A/
Pathologic Murmur :  N/  A/
Gallop Sound :  N/  A/
Lungs : - Left N/ A --------------------------------------------------------------
Describtion --------------------------------------------------------------
; - Right N/ A --------------------------------------------------------------
Describtion --------------------------------------------------------------
Height : Blood Pressure : mm/hg
Weight : Pulse Rate : X/menit
Head : N / A ------------------------------------------------------------
Ears : N / A ------------------------------------------------------------
Nose : N / A ------------------------------------------------------------
Skin : N / A ------------------------------------------------------------
 RUMAH SAKIT KHUSUS BEDAH
KARTIKA DOCTA
Jl. Gajah Mada No.14 – Padang Telp. (0751) 4481278
www.kartikadocta.com email: info@kartikadocta.com

Nerveous System : N / A ------------------------------------------------------------

Lymph Nodes : N / A ------------------------------------------------------------
Perph Vase : N / A ------------------------------------------------------------
Mouth :
Teeth :
87654321 12345678
87654321 12345678
C = Caries R = Root
F = Filling M= Missing

Breast : - Left N / A ----------------------------------------------------------

: - Right N / A ----------------------------------------------------------
Abdomen : N / A ----------------------------------------------------------
Extremities ; N / A ----------------------------------------------------------
CONCLUSION --------------------------------------------------------------------------------------------------------------
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RECOMMENDATION --------------------------------------------------------------------------------------------------------------
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