Guidelines on Medical Examination, Reports, and Medical Certificate Pellegrini Catering Overseas SA IV, HEALTH CERTIFICATE HEALTH CERTIFICATE Full Name (in block letters): DIMAS SURYA BUANA Date of Birth: OG MARCH 199} Occupation: STEWARD This health certificate has been issued on the basis of the Applicant’ s health statement, examination, and evaluation. This Health Certificate is valid until: 21. NOVEMBER 2024 Applicant” s Signature in the Doctor’ s presence Place;__ QUPABATA Day; Month, Year: 21 NovemBe! Doctor’ s stamp, signature, name and address Alvaat Gare 2 Sar man Bas ary be Bo Ta. 0D ROTARY, #21 RAED‘Guidelines on Medical Examination, Reports, and Medical Certificate Pellegrini Catering Overseas SA 6. Overall Summary, Assessment and Recommendations The present medical certificate is valid until: _ X\|_ NOVemBer 2024 Thave examined Mr/Mrs. VIMAS SueYA Ruana and I found him/her (tick the box) X Unfit for duty Fit for OFFSHORE DUTY ey Fit for FOOD HANDLING Unfit for duty ies) Examining Doctor’ s Signature: (stamp, signature, ‘name and address of the Physician). Date:_#| NovemBee 2023, 0/1554/0Guidelines on Medical Examination, Reports, and Medical Certificate Pellegrini Catering Overseas SA 5. ___ Examination Results and Report. 07. A HIV Test 08. Tine (Tuberculin) Test 09. Hoeag — HBsAb [J HBeab HBcAb 10. /VDRL nL Stool Examination 12. Pharyngeal Plug Test Woemac 13. Spinal Column/Lumbar and Sacral X-Ray Report = Nq@MAC.Guidelines on Medical Examination, Reports, and Medical Certificate Pellegrini Catering Overseas SA S, Examination Results and Report X-Ray, ECG, Audiogram and Blood-Urine Laboratory Examination Report All exams, results and tests are to be attached. Please indicate your remarks in case of abnormal results, 01. Chest X-Ray Report Noemar 02. ECG Report NoemMau 03. Audiogram Report Noemac (04. Blood Examination Report (Please attach the results of the following examinations or indicate here below the results): 01, Haemoglobin 09. Basophiles 17. Blood Urea 02. Red cells 10. MCV 18. Cholesterol 03. ESR 11. MCM 19. Total Bilirubin 04. White cells 12. MCHC 20. Direct Bilirubin 05. Neutrophils 13, Platelet 21, Alk. Phosphatase 06. Lymphocytes 14, Reticulocyte 22, SGOT 07. Monocytes 15, Hematocrit 23. SGBT 08, Eosinophiles 16. Sugar 24, Gamma GT 05. Urine Examination Report MoemaL 06. Drugs, Alcohol Screening Test Report NEGATIVE 0Guidelines on Medical Examination, Reports, and Medical Certificate Pellegrini Catering Overseas SA Medical Examiner’ s Report 11. Genitourinary & Digestive System ¢ 4) Is the urine test abnormal? b) Is there any abnormal tenderness, ‘enlargement or other palpable abnormality in abdomen? ¢) Is ahemia present? 12, Nervous System a) Are there any signs of disease in the central nervous system? BB Ss. bb) Is there anything to suggest a tendency to [_] psychiatric disorder? 13, Sense - Organs 8) Is there any affection ofthe eyes, ears, nose or tongue? Vision Far Vision_ Near Vision Colour Vision Tacorecied [RE TE Adequate (Comecied RE GIG Gt Detscuve RATE, Remarks FSI el F |4 Medical Examiner’ s Report Guidelines on Medical Examination, Reports, and Medical Certificate Pellegrini Catering Overseas SA If you answer Yes to any of the following questions, please give full details with any ascertainable cause as applicable. Pleasetickbox — ([X] Yes 08. Measurements & Physical Description 4) Measurements (tobe taken in indoor py clothing) by Please describe general appearance and _y, build ©) Are there any signs of pastor present [] ‘over-indulgence in alcohol, tobacco or irregular lifestyle? 4) Is there any enlargement of lymph Gg iy RS nodes of thyroid gland? @) Are there any scars of material Re significance? 09. Cardiovascular System & Blood Pressure 4) Does the heart appear to be enlarged? If [—] ‘YES, do you consider this tobe slight, moderate or marked? b) Is there any irregularity of rhythm? Ea ) Is there any abnormality ofthe arterial pulse? 4) Are there any varicose veins? ©) Blood pressure: (Please ecord opposite) 10, Respiratory System a) Is there any abnormality in the shape and development of the chest? b) Ate there any abnormal physical signs in the lungs? SS bh ee Details if Yes (including dates & duration and any other relevant info) a a Height: em Weight Kg SystolicDiastolic WG) TF Pulse RateGuidelines on Medical Examination, Reports, and Medical Certificate Pellegrini Catering Overseas SA. 3. Summary of Medical History of Mr/Mrs. Has the Applicant ever had or has now any of the following? If yes, give details in the summary description. OOoo0o0g00 BERERERM = Please tick a box, whether[X] Please tick a box, whether[X] Ye normal or not ‘normal or not < e & 01. Ear Infection/Sinusitis/Vertigo 08, Endocrine disorder (02. Nose, mouth or throat trouble 09, Hemia/HdrocelaPilesFissures 03. Colour Blindness/Loss of Vision 10, Fistula’ Appendicitis/Variocele 04, Frequent Headaches/Finting 11, MalaiaTropical disease 0, Epilepsy/MenalIliness 12. Skin disease 13, Cancer or Tumor 14. Allergy to foods/drugs 06. Hypertension 07, Diabetes mellitus oooo0000 BEE EBREAB RemarksGuidelines on Medical Examination, Reports, and Medical Certificate Pellegrini Catering Overseas SA 1. Personal History 05. Female only: Have you had any 0 synaccological or obstetric problems? &-O 06, Have you ever taken drugs other than prescribed by any doctor AGncluding medicines from a chemist)? 07.) Non smokers: Have you smoked in | the past? 07.) Smokers: How much do you smoke | —> Cpereies Cioars Pe paaet Number Smoked 07. c) What is your average daily > consumption of alcohol? 2.___ Family’ s Medical History Tliving, ‘State of Health dead, Age Cause of Death Age at death Father —s3 HEAUTHS Mother SO. AGACTAS BrotherSiser| 2-4 HEALTHY Brother/Sister Brother Sister I declare that to the best of my knowledge and belief the answers to the above questions are true and complete. I confirm that I have checked and found correct any answers that are not in my handwriting. I grant permission to take samples of blood, saliva and/or urine in connection with this examination. I understand that this statement will be forwarded to the Company’ s Medical Department. Applicant’ s Signature (to be signed in the presence of Medical Examiner) Dae 2] Movember 2023Guidelines on Medical Examination, Reports, and Medical Certificate Pellegrini Catering Overseas SA . Personal History Pleasetick box [X] Yes No Details if Yes 1, a) Are you at present under medical [_] care or receiving treatment? 01. b) Are you currently taking ] ‘medication, prescribed or not, having injections, using an inhaler or have you recently done 50, or are you on any special diet? 02, Have you ever suffered from: 4) fits, fainting, giddiness or any mental or [_] nervous disorder? ) asthma, bronchitis, pneumonia, or any [_] other lung disorder? ©) rheumatism, rheumatic fever, arthritis or [__] any other disorder of joints and muscles? 4) chest pains, shortness of breath, Palpitations, high blood pressure or other Aisorders of the heart or circulation? i BB . ©) indigestion, peptic ulcer, diarthoea, constipation or any intestinal complaint, hepatitis or other liver disorders, diabetes? £ kidney, bladder or other genitor-urinary [_] disorders? £&) any injury, operation, physical defect or deformity? 'h) any other illness not mentioned above? [_] AI ales prowweapinns fa]. A hospital, nursing home or special clinic? 03. b) Have you ever had any medical — [_] A investigation carried out? 04, Have youeverhad any formot — (] A sexually wansmtted disease or is there anything about your lifestyle which could ‘expose you tothe risk of AIDS or AIDS telated condition? ZA (including dates & duration and any other relevant info)Guidelines on Medical Examination, Reports, and Medical Certificate Pellegrini Catering Overseas SA Il. MEDICAL REPORT 1. Personal History ‘Name in full TMA VRYA_RYAwA Date of Birth OG MARCH 1S] Sex M7) F Occupation a eee Badge No. Blood Group [OJ Rh [__]Guidelines on Medical Examination, Reports, and Medical Certificate Pellegrini Catering Overseas SA L INSTRUCTION FOR THE PHYSICIAN The aim of this Form is to grant homogeneous medical procedures for all personnel within Pellegrini Catering Overseas SA Luxembourg ~ Lugano Branch. The Medical Report form includes 3 pages, numbered sequentially. Please avoid swapping pages with different serial numbers. ‘The Head Medical Department requirements need the Physician to complete each section of the form. The medical certificate can be valid for a maximum of I year Section 1 Please make sure that: a) The Applicant answers to all queries on page no. 1. Report your observation on the right side of the page. b) The Applicant signs page No. 1 on the dotted line atthe bottom left comer. Section 3 Please fill out the summary of the medical history of the Applicant and state your remarks on the dotted lines. Section 4 Please fill out all items and the section provided for details, and state your remarks on the dotted lines. Section 5 48) Attach all results of the exams performed and state whether they are within the norm oF wot b) All exams marked in item 4 (Blood Examinations) are mandatory ¢) The HIV test (item 7) shall be done only if required by the Country of work of upon chen requestGuidelines on Medical Examination, Reports, and Medical Certificate Table of Contents L Instruction for the Physician Section 1 Section 3 Section 4 Section 5 Section 6 Il. General Instruction Ill. Medical Report . Personal History Family’ s Medical History 2. 3. Summary of Medical History of Mr./Mrs. 4. 5, 6. Medical Examiner’ s Report Examination Results and Report Overall Summary, Assessment and Recommendations IV. Health Certificate