LAMPIRAN C Ref. No : Photo 4 x 6 ( Part I : Personal information ) 1. FULL NAME ( FIRST NAME) : ( FATHER'S NAME) : 2. MALE/FEMALE : 3. AGE : 7. NAME OF EMPLOYER / RECRUITING AGENCY : 8. ADDRESS OF EMPLOYER / RECRUITING AGENCY : HAS THE WORKER EVER SUFFERED FROM OR EXPERIENCED OR RECEIVED TREATMENT FOR THE FOLLOWING DISEASES AND CONDITIONS? IF " YES " PLEASE INDICATE DATES OF DETECTION 1. HIV / AIDS* 2. TUBERCULOSIS* 3. MALARIA 4. LEPROSY* 5. SEXUALLY TRANSMITTED DISEASES* 6. BRONCHIAL ASTHMA 7. HEART DISEASE 8. HYPERTENSION 9. DIABETES MELLITUS ( COMLICATED OR INSULIN DEPENDENT ) 10. PEPTICULCER 11. KIDNEY DISEASE 12. CANCER 13. EPILEPSY* 14. PSYCHIATRIC ILLNESS* 15. HEARING PROBLEM 16. HEPATITIS 17. OTHERS ( Part II : Medical History ) ( To be completed by Attending Physician ) * To be considered unfit if found positive ( For the rest of disease it is up to the discreation of the examining Physician ) YES NO DATE Page 1
( Part III : Physical Examination and Investigations ) ( This part is to be completed by the examining Doctor / Physician ) ( Section A : General Physical Examination ) 1. HEIGHT : / cm 4. BLOOD PRESSURE 2. WEIGHT : / kg SYSTOLIC : mm Hg 3. PULSE / min DIASTOLIC : mm Hg PRESENT ABSENT 5. CHRONIC SKIN RASH 6. ANAESTHETIC SKIN PATCH 7. DEFORMITIES OF LIMBS 8. ANAEMIA 9. JAUNDICE 10. VISION TEST RIGHT LEFT UNAIDED AIDED 11. HEARING IMPAIRMENT PRESENT ( Section B: Systems Examination ) 1. CARDIOVASCULAR SYSTEM NORMAL ABNORMAL 1.1 HEART SIZE 1.2 HEART SOUNDS 1.3 OTHER FINDINGS 2. RESPIRATORY SYSTEM 2.1 " BREATH SOUNDS " 2.2 OTHER FINDINGS 3. GASTROINTESTINAL 3.1 LIVER 3.2 SPLEEN 3.3 KIDNEY 3.4 IS THERE ANY ABNORMAL SWELLING? YES NO INDICATE IF " YES " 3.5 RECTAL EXAMINATION 4. NERVOUS SYSTEM AND MENTAL STATUS 4.1 GENERAL MENTAL STATUS 4.2 SPEECH 4.3 COGNITIVE FUNCTION 4.4 SIZE OF PERIPHERAL NERVES 4.5 MOTOR POWER 4.6 SENSORY 4.7 REFLEXES Page 2
5. EXAMINATION OF THE GENITOURINARY SYSTEM YES NO 5.1 DISCHARGE 5.2 SORES / ULCERS ( Section C : Laboratory results and X - ray findings ) SPECIMENS FOR LABORATORY INVESTIGATION MUST BE COLLECTED BY THE EXAMINING DOCTORS. THE LABORATORY RESULTS AND X - RAY FINDINGS MUST BE ACCOMPANIED BY THE REPORT CERTIFECATES FROM THE LABORATORY AND FROM THE DOCTOR REPORTING THE X - RAY. 1. BLOOD NEGATIVE POSITIVE 1.1 HIV ANTIBODY ( ELISA ) * 1.2 HBsAg * 1.3 VDRL / TPHA * 1.4 MALARIA PARASITE FOR MALARIA IF POSITIVE GIVE APPROPRIATE TREATMENT AND THEN REPEAT 1.4 DATE WHEN BLOOD TEST FOR MALARIA PARASITE IS FOUND NEGATIVE AFTER TREATMENT 2. URINE EXAMINATION 2.1 ROUTINE EXAMINATION - COLOUR. " SPECIFIC GRAVITY " SUGAR : ALBUMIN NEGATIVE POSITIVE MICROSCOPIC EXAMINATION 2.2 OPIATES / CANNABIS * 2.3 PREGNANCY* * To be considered unfit if found positive 3. SLIT SKIN SMEAR ( IF INDICATED ) 4. CHEST X - RAY REPORT ( Valid for 6 months ) 5. SPUTUM AFB ( IF INDICATED ) : 6. SERUM CREATININE ( To be done in country of origin for worker with history of renal disease hypertension and diabetes mellitus ) 7. RECTALSWAB FOR SALMONELLA ( Only for those in food industry ) Page 3
I HAVE EXAMINED THE ABOVE AND FOUND : ( Part IV : Certification by Physician ) 1. HE / SHE IS FREE FROM THE FOLLOWING DISEASESES : HIV / AIDS TB MALARIA LEPROSY STDS HEPATITIS YES NO 5. I THEREFORE RECOMMED THAT HE / SHE BE CONSIDERED / NOT CONSIDERED FOR EMPLOYMENT ADDRESS OF THE PHYSICIAN QUALIFICATIONS OF THE PHYSICIAN DATE : ( To be retained by the examining Physician ) Page 4
( To be retained by the worker ) APPENDIX A Ref. No Photo 4 x 6 ( Part I : Personal Information ) 1. FULL NAME : ( FIRST NAME ) ( FATHER'S NAME) : 2. MALE / FEMALE : 3. AGE : 7. NAME OF EMPLOYER/RECRUITING AGENCY : 8. ADDRESS OF EMPLOYER/ RECRUITING AGENCY : I HAVE EXAMINED THE ABOVE AND FOUND 1. HE / SHE IS FREE FROM THE FOLLOWING DISEASE * HIV / AIDS * TB * MALARIA * LEPROSY * STDS * HEPATITIS 5. I THEREFORE RECOMMEND THAT HE / SHE BE CONSIDERED/ NOT CONSIDERED FOR EMPLOYMENT ADDRESS OF THE DOCTOR / PHYSICIAN QUALIFICATIONS OF THE PHYSICIAN DATE : PHONE NO : FAX NO : Page 5
( To be retained by the Embassy) APPENDIX A Ref. No Phto 4 x 6 ( Part I : Personal Information ) 1. FULL NAME : ( FIRST NAME ) ( FATHER'S NAME) : 2. MALE / FEMALE : 3. AGE : 7. NAME OF EMPLOYER/RECRUITING AGENCY : 8. ADDRESS OF EMPLOYER/ RECRUITING AGENCY : I HAVE EXAMINED THE ABOVE AND FOUND 1. HE / SHE IS FREE FROM THE FOLLOWING DISEASE * HIV / AIDS * TB * MALARIA * LEPROSY * STDS * HEPATITIS 5. I THEREFORE RECOMMEND THAT HE / SHE BE CONSIDERED/ NOT CONSIDERED FOR EMPLOYMENT ADDRESS OF THE DOCTOR / PHYSICIAN QUALIFICATIONS OF THE PHYSICIAN DATE : PHONE NO : FAX NO : Page 6
( To be retained by the Immigration Department) APPENDIX A Ref. No Phto 4 x 6 ( Part I : Personal Information ) 1. FULL NAME : ( FIRST NAME ) ( FATHER'S NAME) : 2. MALE / FEMALE : 3. AGE : 7. NAME OF EMPLOYER/RECRUITING AGENCY : 8. ADDRESS OF EMPLOYER/ RECRUITING AGENCY : I HAVE EXAMINED THE ABOVE AND FOUND 1. HE / SHE IS FREE FROM THE FOLLOWING DISEASE * HIV / AIDS * TB * MALARIA * LEPROSY * STDS * HEPATITIS 5. I THEREFORE RECOMMEND THAT HE / SHE BE CONSIDERED/ NOT CONSIDERED FOR EMPLOYMENT ADDRESS OF THE DOCTOR / PHYSICIAN QUALIFICATIONS OF THE PHYSICIAN DATE : PHONE NO : FAX NO : Page 7
( To be retained by the Emploment Agent / Employer) APPENDIX A Ref. No Phto 4 x 6 ( Part I : Personal Information ) 1. FULL NAME : ( FIRST NAME ) ( FATHER'S NAME ) 2. MALE / FEMALE : 3. AGE : 7. NAME OF EMPLOYER/RECRUITING AGENCY : 8. ADDRESS OF EMPLOYER/ RECRUITING AGENCY : I HAVE EXAMINED THE ABOVE AND FOUND 1. HE / SHE IS FREE FROM THE FOLLOWING DISEASE * HIV / AIDS * TB * MALARIA * LEPROSY * STDS * HEPATITIS 5. I THEREFORE RECOMMEND THAT HE / SHE BE CONSIDERED/ NOT CONSIDERED FOR EMPLOYMENT ADDRESS OF THE DOCTOR / PHYSICIAN QUALIFICATIONS OF THE PHYSICIAN DATE : PHONE NO : FAX NO : Page 8