PURI MEDIKA MEDICAL CHECK-UP CENTER PREMIER MARITIME CLINIC '$0 S6¢1 245 Cenifed Nartine Clinic Clinic Liconse No: (2/2010 Accrudhed by Minsiry of Heal otha Republi of indonesia Appoint by Sub Direrloraia af Sea Comm, Mnisty of Communicatons, Republe of inconesla SHAPARER MEDICAT, FITNESS CERTIFICATE, (This Medical Cerificate (s'ssued based on Medical Examinalan dene In accordance with STCW requlaicn V8 or ILO-147 (1976) 1LQ, Markima Labour Corvariian 2066 ar ILO Guldance on the MeUical Examination for Seafarers) SEAFARER INFORMATION : Name DAYID CHRISLAND DUNGGU Date of Birth ov2i1981 Gender Male Nationality INDONESIA Job Pasilion / Rank. MASTER ‘Shipping Co, / Manning Agency: PRIVATE, PEME No. 5 O085/PEME-DAPRIN2020 Client No, 2 1612910 Passport No 2» 02829592 ‘Seeman Book No, : DECLARATION OF THE RECOGNIZED MEDICAL PRACTITIONER No, Declaration Yes Ne x 7 | Conlirmation thal identifcalion documents were cheexed al the poini of examination Hearing meets the siandards in STOW Code, se 1 ALS? Unaided heering satsfaciory? Visual acully reais slardards in STOW Code, section ATE? sis) sis Golor vision meels slancards in STOW Cade, section A? Dole of last cclor vision test | \ ogvozi2020 © | Fillorfeckoutdutles? S| 7 | Any limitations or restrictions on fines? v (F'80", specify limitalions or resliicions @ | The sestare” is ree from any medicel condilian likely to be aggravaied by service 7 al sea orto render the seefarer unlil for such service or lo endenger tne health of cher pereons on board. Dale of Examination 9302/2020 Expiry dele of celificale ozrozi2022 Place of Issue 2 Jakarta, INDONESIA Scalarer's signature Medical Review Officer TOIT DAVID CHRISLAND DUNGGU. Dr. Sanjay Singh, M.M... MMR. sa Th Sunes Bawwba Raye 46, Tanja Pluk, Jakives IM, (NDONPSIA w (al-21) 4599 1975 (Tuning) Pass (6 ‘cbvie: wh sepia vem» F-ml: puried-nakecelniby etl « pees pormedica som COPYRIGHT RESERVEO. PMNCIMRCIONIC, 3 00 TSPHYSICAL EXAMINATION €o. / Agency : PRIVATE Exam Dale] 93.09.2090 14:46:30 Examines Name : DAVID CHRISLAND CUNGGU GllentNo. 1812970 dob Rank + MASTER PEMIE No. 86 PEME-DPRUUSO2D Gender ; ite Age: 99 Years Old Crew ID BM BODY BUILT Helaht: 186 Gms} Weight: 6 Kon (on N’ [529-9 [238-298] 0» 40 |Z Poory Developed (1 Wer Developed + Kes Grade |! x Me [Z Overweight (1 Obese Family History Diabetes < D ves J Ne HeartCisease: [] Yes J No Hyreiension: yes [1] No GancerTumor: [] Yes Others Kapplicable, give details : vital Signs Pulse: 72 xim — Reguler BP: 1200 mmHg RR: 20 xm Temps: garg Skin Yer | No Eyes (External) | Yer ] Ne Ears Yer] Ne Taundice —_[7_| | Exonhthaimia = | ~ | | Aalive otits Media ~ 14 Eczema/Psoriesis | 7] Peteric ~ | 7 | [Ottis Extema ~|~ Ganglion Gyst —[e | [Pengume7o > |_| | Ruptreawenbrene ~|¥ Tatins ~ |e | [eataracts = | | | Tumors? Masses < Conjunetiviis = [7] [Hesring toes =~ Gastrointestinal | N [A2N| | Anemic/ Pate ~[¥ Cans TSUN eae ‘Abnormal Vascularty | - | 7 Pharynx/ Or Pherymx | 7 | - Paipitaions Tr Tonsil “|- Respiratory Yes] No | [Arhytnmla’s -|¥ Crganomecal Yea | Ro < rome Asthma /ShortBreating| — | 7) [_Mamur -|¥ oe =| ¥ | | caching mere tent wees | =} 7 | | Extrasyatele / Gallop ~ |" flesh ev Flemonrnord ~17 coven wi oe -{¥ Musculoskeletal | N [ABN Genital External ~|¥ ee E Reflexes @ is sion of prasioua neater? Hernia =| | | ct tacts Orage -|¥ APR vf Fyarocel =| 2 | [Wheezing 7 KER 7[- Waris = [7] [oneal — 7] [eintmovement v[- CORRENTE | HEMARRS | hl ari mA NUGRAMA EARNING PHYSICIAN ‘Created By: RIFKT II, Sungai Bambu Raye No, 46, Tanjung Priok, fakanss 14340, INDONESIA @ (62-21) 4393 1975 (Hunting) Fax: (62-21) 4399 1985 Website: www porimecika.com + E-tnal : purmed-medcea @ceoirin. oct + peme-resul@purimedikt.com ‘COPY RIGHT RESERVED PHM PHY F021 04EYE EXAMINATION REPORT Go. / Agency : FRVATE ExamDate | g.07-2020 18:17:82 Examines Name : DAVID CHRISLAND DUNGSU, Client No. 1612910 Job f Rank : MASTER PEME Ne. oar cnenPoT Gender: Male Age: 32 Years Old Crew iD Pasa Eye Log No, onwrEVEIPRI 2020 Exemal : OD NORIVAL 08 NORMAL Sign of Double Vision CO ves Conjunativas OD OS Sorneat op os Ly Mniection o oa Dy intra aq oo Secret o oa Nebuia o oo orevem QQ (D Mesula o.oo vision Visust Distant Vision iP Near Vision Acuity Unaided Aided Unalged Aided Richteye [67 6 207 20 Lefteye #6 20 20 BolhEye af 6 201 20 “GOLOR VISION (ISHIHARA’S Metfiod ) Normal Ty oetective - Paral Color Sindness . - Tolal Golor Blindness “CONCLUSION : ” VISUAL AQUITY COLOR BLINDNESS Ty O08 Normal oo Normal LD Others: oos ] Defecive ADVICE : Corrective Eyeglassee Spare Glasses LD Rentired ( Having CO Recuires 77] No! Reauired J Buthave to Update C1 Not Required Created By: Citta Rebin Alvin Refractionist 11, Sungai Bambu Rays No, 46, Tanjimg Priok, Jakarra 14330, INDONESIA = (62-21) 4304 1975 (Hunting) Fux; (62.21) 4908 1985 Website: www purimedika.com * E-mail: pirmed-mncdcen @centrin aed « peme-resulr@ puriedika.com PMC EYE 01/01 COPY RIGHT RESERVED aaa eee eee ee TTAUL:OMETRY EXAMINATION RESULT ‘Co. / Agency: Exam Data 03-02-2020 15:02:49 Examinee Name : DAVID CHRISLAND DUNGGU Client No. 1812910. vob / Rank : MASTER PENE. Na. TanESAPnILaren Gender: Male Age: 39 Years Old Crew td. Un-Akied Result Right Ear S00 HZ | 1O0OFZ | ZO0HZ ] S000 He | 4000 Hz @ dB 30 30 20 35 7875 Leh Ear 500 Hz | 1090 Hz | 2000Hz | 3000 Hz | 4000 Hz dB ae 30 20 1S: Ad — Aided Result Right Ear SOU Hz | 1UD0HZ | 2000Hz | 3000 Hz | 4000 Hz 3 dB Tet Ear SOO Hz | 1000 Hz | 2000Hz | 3000 He | 000 He a ab Distance Words Count Result Remarks (if any) em olor 10 ‘Normal [ om TculoF 10 Within Normet Range 4m 0 cutoF = 10 Mild Hearing Loss: am 0 autor 10 Modium Hearing Loos 2m Qo outol = 10 Tm 0 outer 10 ‘Severe Hearing Loss: PILL PuNe/ AUD /02 104ian No sorzst0 Daa of Examination 892-2020 13:20:15 ‘Shppng Go./ Manning Agency pRIVATE PEMENO + On6EIFEME-DAVPRULIZ020 Ful Nome DAVID CHRISLAND DUNCGU Age /Gencer 39 Tahun! Hale This is to certify that I have examined the above Examines and found he/she is dentally FIT. (ON Dig. Susiyanil Ariani Ji, Sungai Bambu Raya No, 46, Tanjung Priok, Jakaria | 4330, INDONESIA ® (62-21) 4393 1975 (Hlunting] Fax: (62-21) 4393 1985, ‘Website: www purimedika,com » E-mail : purmed-redcan@ceavrin.net.id « peme-result@purimedika com COPY RIGHT RESERVED PRMACIDENVOZIONDENTAL EXAMINATION REPORT ‘Co. Agency : PRIVATE, Exam Date 03-02-2020 46:46:10 Examinge Name : DAVIO. CHRISLAND DUNGGU CliantNo rerzeio | Job /Rank: MASTER PEMENS. | _omsreseoveranaiza Gender : Male Age: 39 Years Old Crew ID Peron Dental Log NO. | —_caucenrpnmanzn FINDINGS | FINDINGS DIAGNOSES ‘TREATMENT PLAN ‘TREATMENT DONE Filings + | NI = cy aves Prost: | | 7 oot et Pevledanal Desaen: Missing Teeth: IIL, tl-7, VB Other Signiteane Findings + NIL Panoramic Interpretaiton : NUR. —e COONAN rg Sivan Avian Taye jy Eavinis Ingar dhavah a an/aitan balva anys ih Seien pega crow bray fporgetclanparnvatanelah dktar oi perrkrs gi exya.l Pu Necks MadeaiCheetn Corr Soya NENGLAC pangenalanberswsian yang ebareren ci dear pemakan gi aya erent Silas Ulu I $992 maribebaskan coker gi] nemefsa cl save dan hak Pun Mectka Medial Chea Ceol erhoesp seals Uni dem donut aa undan éanikakrranapun spa inkl ganggean padakeselaian ig 8378 fikerurian nat sibat dev penolkan pargeatarapirawalan reel 1 the bel otned,hawhy dosined Val There buon gron dated inoomalon raged "ay Anal haath aalun quad radislncoalv® wih was RATERS By erst nrion rlasee my atime te Pur Motta Mesa Chockup Cantor and dante! at Put hdlka Medial Check Contr ofan dana press thal ear fa saan Vosahaln Says BT TL Sungai Bambu Raya No, 46, Tanjung Priok, Takarta 14330, INDONESTA 2 (62.21) 4107 1975 (Horting) Fax: (62-71) 4395 1985, ‘Website: www purimediks.com * E-mail : purmed-medcen@censri.ne.id * pome-resalt@purimedika.cotn COPY RIGHT RESERVED, BRIG J DEN F017 04ota, ae a CHEST X-RAY REPORT x f (PA, VIEW) Go. / Agency : PRIVATE Exam Dale 09-02-2020 17:41:49 Examines Name: DAVID CHRISLAND DUNGGU Client fo. 7612910 vob / Rank : MASTER PENE No, CHBSIRENE-ONRUN2NZG Gender = Male Age: 39 Years Old Crew ID Ferra Rad. Log No, (SSRADPRMIEZACD THE LUNG FIELDS : NO INFILTRATES AT BOTH FIELO OF THE LUNGS THE HILL ARE NORMAL BRONCHOVASCULAR MARKING IS NORMAL THE CARDIAC : Normal THE AORTIC CUTLINES : Normal ‘THE COSTOPHRENIC SINUSES : Normal DOMES OF DIAPHGRAM : Notmat SOLETAL ABNORMALITY : NIL OTHER ABNORMALITY : NIL CONCLUSION : HEART AND LUNG NORMAL — CET Dr. |Wayan Murna Y, Sp. Rad RADIOLOGIST Created By: ASEP 2. Sungei Bambu Raya No. 46, Tanjung Prick, Jekurtn 14330, INDONESIA % (62-21) 4395 1975 (Huuting) Fax: (62-21) 4393 [985 ‘Website: www porimedika.com * Bemail : purmed-medcent@cemin neti » peme-resalt@purimedika.cora COPY RIGHT RESERVED PMMC /RAD/ 1/04LUMBAR REPORT Co, /Ageney ! PRIVATE Exam Date 0302-2020 16:18:20 Examines Namo ; DAVID CHRISLAND OUNGGU Client No- ator Job / Rank: MASTER PEWE No, ors we DAPRO@D Gender : Male Age: 39 Years Old Grew ID Porson | Cum. Lag No. oouracrravizaz0 Alignment and Lordatic of iunbosacral vertebrae : normal Lysthesis : no. Scoliosis : no. Lumbar vertebral bodies intact : yes Fracture Detected : no. Ostocphytes : Palvic Bony Structures normal ” Intervertebral disc spaces normal Paravertebral soft licsues nermal CONCLUSION : Lumbosacral Vertapras X-Ray Wilhin Normal Limit (ANCE Dr. Wayan Mura Y, Sp. Rad Grealed By: ASEP TATIOLDGET 5, Songet Bambu Reya No, 45, Tanjung Prios, Jokaro 14330, INDONESIA © (62-11) 4383 1975 (Hunting) Fax: (62-21) 4393 1985 ‘Website: ww parimedik.com + E-mail : purmed-meécen@cestrn.ae. id» peme-restlt @purlmedka com COPY RIGHT RESERVED PMN LUM jot r04ine Co. /Agenoy PIVATE Examinge Name ; DAVID CHRISLAND DUNGGU Job /Rank : MASTER Gender: Male ECG INTERPRETATION : Sinus RhythmiBoats : P Weve = PR interval = ‘Transitional Zone = QRS Axis | QRS Interval : ST Interval LVH RVH ; Lape : RBBB : ST Changes = Age: 39 Years Old 68 (Reguler Narmal Normal vava Normal Normal Normal Negative Negative Negative Negative Negative CONCLUSION / IMPRESSION Within Normal Limit ADVICES | RECOMMENDATIONS : Created By: DEBORA JL Sungai Bauabu Raya No, 46. Tanjung Privk, Jakarta 11350, INDON Website: woe, purianeaila cons » E-anidl + panilwedoen een COPY RIGHT RESERVED 1A 8 t02 Exam Date 03-02-2020 00:00:00 Client No. 1612970 PEME No. O5SPEME-DAPRINZO Crew ID ECG Log No. ‘omecamnz929 114393 1975 (Hunting) Pax: (62-21) 4393 19HS whid = pere-esul @parinieaseon PANG PHY F0a/ 01LABO” ATORY RESULT REF )RT ical Pathologlst : Dr. Hana DK. Horasio, Sp. PK Shiping Co./ Manning Agency ; PRIVATE Full Name + DAVID CHRISLAND DUNGY Lab. No : 20002737 age / Gender :38 Years / Male Collected Date: 03-02-20 13:54 sLient Wo. qaeizs10 Validate Pate : 03-02-20 16:01 JENE No. + 0065/PEME-DA/PRI/11/2020 Report Date: 03-02-20 16:01 Taboratory Test Resulta Unit Reference Range smmnsonosy/eac senogiopin 15.3 a/at 13.5 - 18.0 wa 6.3 10°3/an 45+ 11.0 _ aR 5.3 10"6/ak 4.60 - 6.20 haenatokris/20v a5 ¥ 10 - 54 BSA 8 ne/nours < 10 Digferential Count Bacophil 8 ‘ 1 zosinopnit 3.0 s <3 Nevt zophtl S78 8 50 - 70 Linphoryte 31.9 * 22 ~ 40 Monacyce 7.0 + ae 3 Platelet 203 10°3/ay 150 = 40 4 ee 85 im BO - 96 ca 28 pofoeL) 27 31 ‘| cc 36 g/l 32 - 36 . Bloed Group + Rhesus lead Group ° Bhooe Positive BLOOD CREMESTAY Slocase Fascirg 200 ng/t 70 - 100 exeetinice 1.2 ng/at. 7-22 so! 20 osu 645 SGPT 36 of <4 eMWoLOSY/sERCLOGY AntAwAY oH Won Reactive Non Reactive Beng ECLIA Men Rezerive Nien Reactive Anti HOV Total ECLIA Non Reactive Non Reactive Ants #IV 142 Eclia Non Reactive Non Reactive BER Negative negative vamenests Macroscopic pH (Reacclon) 6.0 50-70 Specific Gravity 2010 aouo = 1030 Protein Wegative Negative Glucose (urine! Megacive Negative Keto Negative negative Bilicubin Negative Negative Blood Negative Negative seukocyte Megacive Negative Sungai Bambu Raya We.46,Fanjung Priok,Jakarta 14139, INDONESIA Ph (62-21) 4392 1975 (iunting)Wen: (62-21) $393 1965 websize ¢ wen. furinedika,com, Email ; pirmed-nedeentcentrin net .i¢, peme-resul tepurinedixs.com ORY RIGHT RESERVED Page 1 of 2 DE /EAB/O1/01a LABO™ ATORY RESULT REFRT Clinical Pathologist : Dr. Hana DK. Horasio, Sp. PK or eh "ea ahiping Co./ Manning Agency : PRIVAT mall Name DAVID CARESEAND PINIGGD tab. Yo : 20002727 Age / Gender 3B Years / Male Collected Date: 97-02-20 13:54 Tien Ne. + 1612810 Validate Dale : 03-02-20 16:02 ?EME No, 0065/Paue-on/Par/1r/2020 Report Dake 93-02-20 16:01 Laboratory Test Results Unit Reference Range Nitrite Negative negative Urobilinogen on g/d. 22 Microscopic /Sediment Ephitels 9-2 IMPE <3 awe 0-2 JHeE 23 rac oz ee 52 cast/cylinder Negative Regetive crystal Negacive Nogariva Bacterle Negecive negetive Ochers Regative Negative sroor, STOOL ANALYSIS Macroacepic Colour Brown Geneiatanay Soft vascnazge Negative Negative Blood Negetive Negative Micromsepia wac/nge 3 wee.purivecthe com, tuail : pumnad-aedcenteantric.xet.id, peme-rerulttpurimedika. com cory RIGHT RESERVED paye Daf d Prac 702 /EEE AEE Go. / Agency : PRIVATE Exam ale — | 99.97.2920 14:42:36 Examines Name ; DAVID CHRISLAND DUNGGU Client Ne. 1612810 vob i Rank : MASTER PEWE No. OORRENE-OAPRUNECZO Gender : Nale ‘Age :39 Years Old Crew Peon Lab Log No. ozzmsareuv2020 fhis is (0 Ceriffy that the above Examinee had beon examined for the presence of the following Drugs in the urine using the Rapid Test based on Competitive Immunoassay / Chromatographic Absorbent method and tor Alcohol with respective method mentioned below, and rosulls are as follows : Opiates / Morphine ; Negative Marijuana / Cannablnoids / THC : Negative Coc legative Phancylidine ( PCP) : Neg: o Alcohol (Saliva - Enzymatic Method) : Negative Metamphetamine : Negative Significant Alcehol Level in the Blood was : NIE% Jakarta, 03-02-2020 TAINO Lab, Analyst J. Sungai Barbu Raya No. 46, Tanjung Prk, Sekar 14330, INDONESIA # (62-21) 4393 1975 (Hunting) Fax: (62-21) 499 1989 ‘Websice, wsrw purimedika com * E-mail: pazmed-medeen @centrnane. bd» panro-result purimecika.com PHC {AB 02/04 COPY RIGHT RESERVED(CONFIDENTIAL) PSYCHOLOGICAL EVALUATION PROrILE Psychologyst Go, } Agency : PRIVATE Exam Date 04-02-2020 03:1 Examinee Name : DAVID CHRISLAND DUNGGU Client We. 7812910 vob / Rank: MASTER PEME, No. OSS FENE-OH/PRUWZIZE Gender: Male Age: 39 Years Old crew id, Physe, LegNo. | acapnvscienvuozo [TEST ADMINISTERED: [] INTELLEGEWCE TEST/ PERSONALITY TEST / Dorner: i T INTELLECTUAL LEVEL i 1, PERSONALITY TRAITS AND CHARACTERISTICS — TAG 1 PARAMETER OF EVALUATION 7 2 z a E 1 1, RESTRAINT | Persovering 7 Obedient 7 Set Discipline 7 Fihustaeile 7 j Venturesome 7 | Z EMOTIONAL STABILITY ‘Gan wihstand isolalfon and Boredom 7 | Faces Realily v Confident v “Tolerance to Stress 7 Relaxed 7 3. OBJECTIVITY ‘| Rearste 7 Free of Suspicions 7 ‘Adaplable v t Practical Minded v 4. MOTIVATION Reserve v independent 7 Resourceful 7 5. GOAL ORIENTATION Can understand instruction and apply in the Job v CONCLUSION / REMARKS - Recommended / Na significant manifestation & cisturbance noted at lhe ime of evaluation REMARKS : ram a EXAMINING PSYCHOLOGYST MEDICAL REVIEW OFFICER = IANA (CONN S.asenge lowe | Beton SEER _ ee Dr. Sanjay Singh, MM., MMS: J. Sungai Bamvu Raya No. £6, Tanjung Priok:, Jakarta 14330, INDONESIA @ (62-21) 4393 1975 (Hunting) Fax: (62-21) 4393 1985 Wetnile: ww purimedikacom + E-mail : pumedemedecn @eentrin.oetid + peme-tesult@purimedike.com COPY RIGHT RESERVED PMIAC FSI 104/04ULTRASONOGRAPHY REPURT Co, / Agency : PRIVATE Exam Date 09-02-2020 Examines Name ! DAVID CHRISLAND DUNGGU Cilent No, 1612010 Job Rank: MASTER FEME No. (RS PEMESDARAIZ2020 Gender: thele Ago: 39 Years Old Crew ID US Log No. OnSUSSVPRIIIAOED Kind of Exarination : Dear Coteague, The abdomen ultresonography findings: Liver: nowralin size and contaur, smooth surface, norme-schols, homogeneous parenchyma echo-structures, Na sign of SOL. Intra-hepatic vascularity and billy traci gre nonmal, No sign of ascllas anc no sign of ploural offusion. Gallbladder; normal in size, shape, contour and surface. No sign of SQListones/sludge. Pancreas ; normal in size, shape, contour and surface. No sigr of focal lesfon/ SOL, Pencteallc duct is normal. Spleen : nofmal in size and contour which are homogensous. No sign of ‘oval lesion / SOL. Right Kidney : Normal size and shapes, Structure of cortex and medulla were normal. Tha cortex- ™medullaratio was normal. No fecal lesion seen. No detecled of calouli/stone(s) and no ‘obstruction of the urinary trac Left Kidney : Normal size and shapes. Structure of cortex and mecutla were normal. The corlex-medullaratio ‘was normal, No focal ‘esion seen, No datecied of calcul/stone(s} and no absituction of the urinary wact Abdominal aorta :normal Urinary bladder: normal In siza, contour end surface, No sign cf stones / focal lesion. Prostate gland: normal in size and shape which are homogeneous echoes and no sign of focal issie CONCLUSION : + Liver, galtbladder, pancreas, spleen, both kidneys, abdominal aorta, urinary bladder and prostate gland were normal Thank you, OTN Created By: ASEP Dr. |Wayan Mumma Y, Sp. Rad RADIOLOGIST Fi. Sungai Bambu Raya No, 46, Tanjung Friok, Jakarta 14330, INDONESIA © (62-21) 4293 1975 (Hunting) Fan: (62-21) 4399 1985 ‘Website: www purtmediks.com * E-rvail : purmed-medcer @centrin.netid * peme-resull @purimedika core COPY RIGHT RESERVED PNMC | RAD /02/ 04 Sn aR SS SESS