DOLE/BWC/HSD/OH-47-A

Republic of the Philippines

DEPARTMENT OFLABOR AND EMPLOYMENT
Region III, City of San Fernando (P)

ANNUAL MEDICAL REPORT FORM

For Period January 1, 20___ to December 31, 20___

1. Name of Establishment : ___________________________________________________________

2. Address : ________________________________________________________________________
3. Name of Owner/Manager : __________________________________________________________
4. Nature of Business and Production/Service (Ex. Manufacturing Textile): ____________________
5. Total Number of Employees: __________________ Number of Shifts: _______________________
6. Number Distribution of Employees as to nature / workplace, sex and workshift:
Office / Admin Production / 1st Shift Production / 2nd Shift Production / 3rd Shift
Male : Female: Total: Male : Female: Total: Male : Female: Total: Male : Female: Total:

7. Preventive Occupational Health Services: (Check or Cross)

a. Occupational health services is organized/provided by: ( ) the establishment/undertaking
( ) government authority/institution ( ) other bodies/groups/institution (specify) ______________
b. Occupational health services as described under number 7a above, is organized/provided as a Service:
( )solely for the workers of the establishment/undertaking ( )common to a number of establishments/undertakings ________
c. The employer engages the services of:
( ) Occupational Health Practitioner - Name & Address : ______________________________________
( ) Occupational health physician - Name & Address : ______________________________________
( ) Occupational health dentist - Name & Address : ______________________________________
( ) Occupational health nurse - Name & Address : ______________________________________
d. The occupational health physician/practitioner/nurse/personnel conducts an inspection of the workplace:
( )once every month ( )once every two (2) months ( )once every three (3) months ( )once every six (6) months ( )other details ______

8. Emergency Occupational Health Services:

a. The employer provides a treatment room/medical clinic in the workplace with medicines and facilities:
( ) yes ( ) no ( )others, please specify _________________________
b. Schedule of attendance in the workplace : Work shift Work shift
Occupational health physician : ___hrs./day _____ Occupational health practitioner : ___hrs./day _____
Occupational health dentist : ___hrs./day _____ Occupational health nurse : ___hrs./day _____
nd rd
Schedule of attendance of full time first aider: ( ) 1st work shift ( ) 2 work shift ( ) 3 work shift
c. The following occupational health personnel of the establishment have undergone training in occupational health and safety/first aid:
( ) Occupational Health Physician ( ) Occupational Health Dentist
( ) Occupational Health Nurse ( ) First Aider ( ) Others, please specify _________________

9. Occupational Health Services:

a. The occupational health personnel of this establishment conducts regular appraisal of the sanitation system in the workplace:
( ) yes ( ) no
b. Number of workers who underwent the following medical examination:
Physical Exam X-Rays Urinalysis Stool Exam Blood Test ECG Others
1. Pre-placement
2. Periodic
3. Return to work
4. Transfer
5. Special
6 Separation

10. Report of Diseases:

a. Number of consultations/treatments for the following diseases:
Skin: Male Female Total Head: Male Female Total
( ) allergy ( ) tension headache
( ) dermatoses ( ) Others
( ) infection as folliculitis Mouth & ENT: Male Female Total
( ) abscess/paro nychia ( ) Gingivitis
( ) Others ( ) Herpes labiales/nasalis
Eyes: Male Female Total ( ) Otitis Media/Externa
( ) error of refraction ( ) Deafness
( ) bacterial/viral ( ) Menlere’s Syndrome/Vertigo
( ) conjunctivities ( ) Rhinitis/Colds
( ) cataract ( ) Nasal Polyps
( ) Others ( ) Sinusitis
Neuromuscular/Skeletal/Joints: Male Female Total ( ) Tonsillopharyngitis
( ) Peripheral Neuritis ( ) Laryngitis
( ) Torticollis ( ) Others
( ) Arthritis Respiratory: Male Female Total
( ) Others ( ) Bronchitis
Infectious Diseases: Male Female Total ( ) Bronchial asthma
( ) Influenza ( ) Pneumonia
( ) Typhoid/paratyphoid fever ( ) Tuberculosis
( ) Cholera ( ) Pneumoconiosis
( ) Measles ( ) Others
( ) tetanus Heart and Blood Vessel: Male Female Total
( ) Malaria ( ) Hypertension
( ) Schistosomiasis ( ) Hypotension
( ) Herpes Zoster ( ) Angina Pectoria
( ) Chicken Pox ( ) Myocardial Infraction
( ) German Measles ( ) Vascular disturbances in
( ) Rabies extremeties due to
( ) Others continuous vibration
Lymphatics and Circulatory: Male Female Total ( ) Others
 ( ) Anemia Gastrointestinal: Male Female Total
( ) Leukemia ( ) gastroenteritis/diarrhea
( ) Cerebrovascular Accidents ( ) amoebiasis
( ) Lymphadenitis ( ) gastritis/hyperacidity
( ) Lymphoma ( ) appendicitis
Reproductive: Male Female Total ( ) infectious hepatitis
( ) Dysmenorrhea ( ) liver cirrhosis
( ) Infection (Cervicitis) (vaginitis) ( ) hepatic abscess
( ) Abortion (Spontaneous) (Threatened) ( ) cancer (hepatic/gastric)
( ) Hyperemesis Gravidarium ( ) ulcer
( ) Uterine Tumors ( ) Others
( ) Cervical Polyp/Cancer Genito Urinary: Male Female Total
( ) Ovarian Cyst/Tumors ( ) Urinary tract infection
( ) Sexually-Transmitted diseases ( ) Stones
( ) Hernia (Inguinal) (Femoral) ( ) Cancer
( ) Others ( ) Others

Diseases due to Physical Environment:

Diseases due to Noise and vibration Male Female Total Male Female Total
( ) Deafness (noise induced) ( ) Musculo-skeletal disturbances
( ) White fingers disease ( ) Fatigue
Diseases due to Temperature And Humidity abnormalities:
Hot Temperature: Male Female Total Male Female Total
( ) heat strokes ( ) dehydration
( ) heat cramps ( ) heat exhaustion
( ) others
Cold Temperature: Male Female Total Male Female Total
( ) Chilblain ( ) immersion foot
( ) frost bite ( ) general hypothemia
( ) others
Diseases due to Pressure Abnormalities: Male Female Total Male Female Total
( ) Decompression Sickness: ( ) barotrauma
( ) air emboism ( ) hypoxia
( ) bends disease ( ) altitude sickness
Diseases due to radiation: Male Female Total Male Female Total
( ) cataracts ( ) burns
( ) keratitis ( ) radiation-related cancers
11. Report of Occupational Accidents/Injuries:
Nature Male Female Total Nature Male Female Total
Contussion, bruises, hematoma Crushing Injuries
Abrasions Spinal injuries
Cuts, lacerations, punctures Cranial Injuries
Concussion Sprains
Avulsion Dislocation/Fractures
Amputation, loss of body parts Burns
12. Immunization Program (Indicate number immunized)
Male Female Total Male Female Total
Tetanus Toxoid Injection Hepatitis B Vaccine
Tetanus Antitoxin Injection Rabies Vaccine
Tetanus Globulin Injection Others (Please specify)

13. Keeping of Medical records of Workers (Please check) ( ) done ( ) not done
14. Health Education and Counselling by Health and Safety Personnel: (Please check one or more)
( ) done individually as each worker comes to the clinic for consultation. ( ) done in organized group
discussions/seminars. ( ) done with the use of visual displays and/or promotional materials, leaflets, etc.
15. Other Health Programs: (Please check)
Kinds of Program Seminar Visual Aid Counselling
Seminar Visual Aid Counselling Family Planning Program
Nutrition Program Mental Health Activities
Maternal & Child Care Persoal Health Maintenance
Physical fitness Program: (Please check) Sports Activities ( )Yes ( )No Others (Please specify) ( )Yes ( )No
16. Hazards in the workplace: (Please check and give details of the substance)
Substances and/ # of Workers Substances and/ # of Workers

Chemical Hazards: or Sources Exposed Physical Hazards: or Sources Exposed

( ) Dust (Ex. Silica dust) ( ) Noise

( ) Liquids (Ex. Mercury) ( ) Temperature/humidity
( ) Mist/fumes/vapors (Ex. Mist ( ) Pressure

from paint spraying) ( ) Illumination

( ) Gas (Ex. CO, H2S) ( ) Radiation/ultraviolet/microwave

( ) Others (please specify) (Ex. Solvents) ( ) Vibration

Ergonomic Stress:
( ) Exhausting physical work Biological Hazards:
( ) Prolonged standing ( ) Viral
( ) Excessive mental effort ( ) Bacterial

( ) Unfavorable work posture ( ) Fungal

( ) Static/monotonous work ( ) Parasitic

( ) Others, specify ( ) Others

Submitted by: __________________ ____________ Noted by:

Medical Personnel/Title Date

________________________________
Employer / Authorized Signatory
hmg