Professional Documents
Culture Documents
Production/Shop
2nd Shift
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3rd Shift
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b.
c.
d.
8.
Name: __________________________________________________________________________________
Address: ________________________________________________________________________________
The occupational health physician/practitioner/nurse/personnel conducts an inspection of the workplace:
The employer provides a treatment room/medical clinic in the workplace with medicines and facilities:
( ) Yes _____________
( ) No _________________
( ) others, please specify ______________________________________________________________________
___________________________________________________________________________________________
b.
-2c.
d. The following occupational health personnel of this establishment have undergone training in occupational health and
safety/first aid:
( ) occupational health physician
( ) occupational health nurse
( ) first-aider
( ) others, please specify _________________________________________________________________
___________________________________________________________________________________
9.
10.
1.
2.
3.
4.
5.
6.
Pre-placement
Periodic
Return-to-work
Transfer
Special
Separation
1.
2.
3.
4.
5.
6.
Pre-placement
Periodic
Return-to-work
Transfer
Special
Separation
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Stool Exams
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X-rays
Urinalysis
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Blood Test
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ECG
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Others
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Report of Diseases
a.
Number of cases diagnosed/treated for the following diseases ((/ of X):
Male
Female
( ) allergy
( ) dermatoses
( ) infection as folliculitis/
absecess/paronychia
( ) Others
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( ) migraine headache
( ) tension headache
( ) Others
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(
(
(
(
Error of refraction
Bacterial/Viral conjunctivities
Cataract
Others
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Skin:
Head:
Eyes:
)
)
)
)
-3Male
Female
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Genito-Urinary:
( ) Urinary Tract Infection
( ) Stones
( ) Cancer
( ) Others
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Reproductive:
( ) Dysmenorrhea
( ) Infection (Cervicitis)
(Vaginitis)
( ) Abortion (Spontaneous)
(Threatened)
( ) Hyperemesis Gravidarum
( ) Uterine Tumors
( ) Cervical Polyp/Cancer
( ) Ovarian Cyst/Tumors
( ) Sexually-Transmitted Diseases
( ) Hernia (Inguinal)
(Femoral)
( ) Others
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Neuromuscular/Skeletal/Joints:
( ) Peripheral Neuritis
( ) Torticollis
( ) Arthritis
( ) Others
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Infectious Diseases:
( ) Influenza
( ) Typhoid/Paratyphoid Fever
( ) Cholera
( ) Measles
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Respiratory:
( ) Bronchitis
( ) Pronchial Asthma
( ) Pneumonia
( ) Tuberculosis
( ) Pneumoconiosos
( ) Others
Heart and Blood Vessel:
( ) Hypertension
( ) Hypotension
( ) Angina Pectoris
( ) Myocardial Infarction
( ) Vascular disturbances
in extremeties due to
continuous vibration
( ) Others
Gastrointestinal:
( ) Gastroenteritis/Diarrhea
( ) Amoebiasis
( ) Gastritis/Hyperacidity
( ) Appendicitis
( ) Infectious Hepatitis
( ) Liver Cirrhosis
( ) Hepatic Absecess
( ) Cancer (Hepatic/Gastric)
( ) Others
-4Male
Female
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Nature
Male
Female
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(
(
(
(
(
(
(
(
(
)
)
)
)
)
)
)
)
)
Mumps
Tetanus
Malaria
Schistosomiasis
Herpes Zoster
Chicken Fox
German Measles
Rabies
Others
12.
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13.
14.
15.
( ) done
( ) not done
Counselling
a.
b.
c.
d.
( ) Yes
( ) Yes
( ) Yes
( ) No
( ) No
( ) No
______________________
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Physical Hazards:
( ) noise
( ) temperature/humidity
( ) pressure
( ) illumination
( ) radiation/ultraviolet/microwave
( ) others (please specify)
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Biological Hazards:
( ) Viral
( ) Bacterial
( ) Fungal
( ) Parasitic
( ) Others
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Ergonomic Stress:
( ) Exhausting physical work
( ) Prolonged standing
( ) Low Back Pain
( ) Unfavorable work posture
( ) Static/monotonous work
( ) Others, specify
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Chemicals Hazards:
( ) dust (Ex. Silica dust)
( ) liquids (Ex. Mercury)
( ) mist/fumes/vapors
(Ex. Mist from paint spraying)
( ) gas (Ex. CO, H2S)
( ) others (please specify)
Submitted by:
___________________________________________
Medical Personnel/Title
______________________________
Date
Noted by:
__________________________________________________
Employer