Page 1

Pre-employment Medical Screening

PETROFAC E-COM PRE- EMPLOYMENT MEDICAL EXAMINATION FORM Date__________________ Requested by:

Job no.:

PERSONAL DETAILS:

Surname

Job Title

First Name

DOB

Marital Status

Sex M/F

Nationality

Badge Number

Home address and phone number

• The Medical History should be filled in the presence of the Physician. • For any details please contact the Petrofac Health advisor on 00971 50 2129996 or mail us at shj-health.section@petrofac.com

Page 1 of 9


Pre-employment Medical Screening

A-MEDICAL HISTORY Is there any FAMILY HISTORY of: ILLNESS Heart disease

Y

N

ILLNESS Nervous or mental disorder High blood pressure Epilepsy Stroke Allergy Cancer Tuberculosis If yes to any of the above questions, Please give details:

Y

N

ILLNESS Diabetes

Y

N

Kidney disease Leprosy Any infectious diseases

Do you suffer from or have you had any: Cardiovascular (heart and blood) system Y Any known heart disease, heart attacks, deep vein thrombosis, blood disorders.

N

*If yes, please specify the medications being used & the consulting medical facility

Respiratory (lung) system Y Any lung disease that prevents you from walking or climbing such as emphysema, chronic bronchitis, Asthma or Pneumothorax (punctured lung).

N

*If yes, please specify the medications being used & the consulting medical facility

Neurological (nervous) system Y Do you have a history of Epilepsy, strokes (CVA) or transient ischemic attacks ( TIAs), fractured skull, Depressive illness or other psychiatric illness, faints/black outs, vertigo, fear of Heights or spaces. If yes, please specify the medications being used & the consulting medical facility

Page 2 of 9

N


Pre-employment Medical Screening

Glandular (endocrine) system Do you have any thyroid disorder Y I*If yes, please specify the medications being used & the consulting medical facility Are you suffering from Diabetes or taking any Insulin?

N

Y

N

Musculo-Skeletal (joints, muscles & bones) Y Plaster of Paris at present on a limb, Back problems or other joint problems including injury/ arthritis, any deformities’ or physical disability.

N

*If yes, please specify the medications being used & the consulting medical facility

*If yes, please specify the medications being used & the consulting medical facility Gastro-intestinal (gut, abdomen, stomach or bowel) Any recent surgery, bleeding, ulcer, hernia ,liver diseases(hepatitis)

Y

N

Y

N

Eyes, ears, nose & throat Y Recent surgery, bleeding, sinusitis, perforated ear drum, ear infections and congestion.

N

*If yes, please specify the medications being used & the consulting medical facility

Skin Any infectious disease, Psoriasis, Eczema, allergies etc. *If yes, please specify the medications being used & the consulting medical facility

*If yes, please specify the medications being used & the consulting medical facility

Page 3 of 9


Pre-employment Medical Screening

Tropical Do have history of Malaria, Typhoid, , Dengue fever, etc.

Y

N

Y

N

Y

N

Y

N

*If yes, please specify the medications being used & the consulting medical facility

Obstetrics & Gynecology Pregnancy, recent miscarriage, Gynecology problems *If yes, please specify the medications being used & the consulting medical facility

Did you have any recent Trauma/ Surgery? *If yes, please specify the medications being used & the consulting medical facility Do you take any regularly prescribed drugs or other medicines? Details:

Are you (as part of your job) exposed to: Y N Y Noise Pollution or inhaled sensitizers / irritants Details:

Smoking Habits: Never smoked Ex-smoker Years smoked: Current smoker Years smoked: Number of cigarettes currently or previously smoked per day? Alcohol Intake:

Y

N

N

Date stopped:

Y

N

Do you intake alcohol? How much do you drink in a typical week? ___________________________ (Note: 1 drink/unit of alcohol is equivalent to 1 glass of wine/ 7oz or half pint beer/ 1 oz or single measure spirits) I acknowledge that any incorrect statement furnished above is cause for my application to be rejected or my employment to be terminated as per Petrofac policy.

Signature:

Date:

Page 4 of 9


Pre-employment Medical Screening

B. FOLLOWING TESTS ARE REQUIRED FOR ALL PERSONNEL – This part to be filled by the doctor completely CLINICAL EVALUATION:

Normal

Abnormal

Eyes & Pupils

Abnormal

Cardiovascular system Abdomen Hernia Nervous system Skin Musculoskeletal system Genitourinary

Ears Nose Teeth & Mouth Tongue Lymph nodes Respiratory system Pulses

Blood Pressure

Normal

Rectal examination

Pulse

Temperature (°C)

Height (cm)

Weight (kg)

CHEST X RAY REPORT: PLEASE ATTACH RESULTS Conclusion

Comment:

□ Normal □ Abnormal LEPROSY PHYSICAL CHECK:

□ Normal □ Abnormal LABORATORY RESULTS: HAEMATOLOGY: Test Hemoglobin, g/dl Ht, % Platelets /l WBC Lymphocytes % Granulocytes % ESR Peripheral smear (high Altitudes)

Result

Normal Male 14-18 40-54 150-450 4.0-9.0 18-41 44.2-80.2 Blood Type:

Page 5 of 9

Female 12-16 37-47

Body Mass Index


Pre-employment Medical Screening

BIOCHEMISTRY: Test LIVER FUNCTIONS

Results

Bilirubin, total, mg/dl SGOT/AST SGPT/ALT, u/l GGT, u/l Alk phos, u/l

Normal <1.3 <40 <41 11-50 38-126

<33 <32 7-32

KIDNEY FUNCTIONS Urea, mg/dl Creatinine, mg/dl

10-50 0.6-1.1

0.5-0.9

Electrolytes LIPID PROFILE CHOLESTEROL Total, mg/dl HDL, mg/dl LDL, mg/dl Triglycerides HbA1c / FBS

<200 no lower than 35 mg/dl Up to 129 mg/dl less than 150 mg/dl

PSA (if above 50 years of age)

Test

Results

HBsAg HIV HCV VDRL(Syphilis ) PPD (if chest x-ray is abnormal, or there is old TB, or any doubt)

URINE TEST: Urobilinogen, mg/dl Specific gravity Leucocytes Bilirubin

Blood/Hb Blood / Ery/ml Glucose Ketones

Protein mg/dl PH Nitrite Ascorbic acid

URINE DRUG SCREEN: Amphetamine: Cocaine: Morphine:

Phencyclidine: Benzodiazephine: Cannabinoids:

Page 6 of 9

Methamphetamine: Heroin: Codeine:


Pre-employment Medical Screening

VISION: Vision Left

No Spectacles Right

6/

Distant

6/

With Spectacles Left Right 6/

Color Blindness ‰ Normal

6/

‰

Red /Green Absent

‰

Totally Absent

Near Visual Fields

Fundoscopy

AUDIOMETRY:

(Required for plant operators/drivers/exposure to noise)

Conclusion ‰

Normal

‰

Abnormal

Comment:

PEAK FLOW RATE: (Required only for exposure to high altitudes) Conclusion

Comment:

Peak flow rate Spirometry

BLOOD O2 SATURATION: Conclusion ‰

Normal

‰

Abnormal

(Required only for exposure to high altitudes) Comment:

STOOL TEST: (Required for food handlers, or if clinically indicated) Conclusion

Comment:

Occult Blood

Page 7 of 9


Pre-employment Medical Screening

ECG:

PLEASE ATTACH RESULTS (Mandatory for those < 40 years old) Conclusion

‰

Normal

‰

Abnormal

Comment:

STRESS TEST RESULT :( Mandatory for those above 40 years old, or if medically indicated for those <40 years old) Conclusion ‰

Normal

‰

Abnormal

Comment:

CURRENT VACCINATIONS (If Recommended by the examining doctor)

Vaccine Diphtheria Rubella

Polio

Past History

Date Done

Date Due

Vaccine MMR Meningitis ARC Typhoid

Mumps

Hepatitis A Hepatitis B Tetanus

Yellow Fever Measles

Rabies

Page 8 of 9

Past Date Done History

Date Due


Pre-employment Medical Screening

CONCLUSION:

RECOMMENDATIONS

• • • • • • • •

Physician’s Name (Print)

:

Position

:

Name of Medical Practice

:

Address

:

Telephone

:

E-Mail

:

Stamp

I hereby declare that the above mentioned medical practice has carried out the tests so indicated in this document and that the results have been faithfully recorded by me.

Physician’s Signature :__________________________________ Date: ________________

Page 9 of 9

ssfjvvk  

sajbkbjk .,m ;bohjvlk j/

Read more
Read more
Similar to
Popular now
Just for you