Republic of the Philippines

Department of Labor and Employment

National Capital Region

ANNUAL MEDICAL REPORT FORM

For Period January 1, 2019 to December 31, 2019

1. Name of Establishment: EMPIRE CREDIT AND COLLECTION MANAGEMENT INC.

2. Address: UNIT 2301, 23RD FLOOR, JOLLIBEE PLAZA BLDG., F. ORTIGAS JR.
ROAD, ORTIGAS CENTER, PASIG CITY

3. Name of Owner/ Manager: JOEBERT G. REYES

4. Nature of Business & Product/ Service (Ex. Manufacturing – textile) COLLECTION

5. Total Number of Employee: 72 Number of Shift: 1

6. Number Distribution of Employee as to nature/workplace, sex & workship:

office Product/Shop
1st Shift 2nd Shift 3rd Shift
Male : 41 41
Female: 31
Total: 72

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

a. Occupational health service is organized / provided by:

() the establishment / undertaking

( ) government authority / institution
( ) other bodies / group / 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 /

undertakings
( ) common to a number of establishment / undertaking

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 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: Melissa David, RN
Address: Unit 3/A 3/F Strata 2000 Bldg. F Ortigas Jr. Road, Ortigas
Center, Pasig City

d. The occupational health physician/practitioner/nurse/personnel conducts an

inspection of the work place:

() 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 work place with
medicines and facilities

()Yes ( ) No
( ) others, please specify

b. Schedule of attendance in the work place:

Work shift
Occupational health physician : hrs./day
Occupational health dentist : hrs/day

c. Schedule of attendance of full time first aider

()1stwork shift
( )2nd work shift
( ) 3rd work shift
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 d. The following occupational health personal of this establishment have under
gone training in occupation health and safety/first aid :

( ) Occupational health physician

( ) Occupation health dentist
() Occupation health nurse
( ) first - aider
( ) Others, please specify___________________________________________
____________________________________________________________

9. Occupational Health Services

a. The occupational health personnel of this establishment regular appraisal of

the sanitation system in the workplace:

( ) Yes () No

b. Number of workers who underwent the following medical examinations:

Physical
Exam X-rays Urinalysis
1. Pre-placement
2. Periodic
3. Return-to –work
4. Transfer
5. Special
6. Separation

Stool Blood ECG Others

Exam Test
1. Pre-placement ______ ______
2. Periodic ______ ______ ______ ______
3. Return-to-work ______ ______ ______ ______
4. Transfer ______ ______ ______ ______
5. Special ______ ______ ______ ______
6. Separation ______ ______ ______ ______

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10. Report of Diseases

a. Number of consultations/treatments for the following diseases:

Male Female Total No.

Of Cases
Skin:

( ) Allergy N/A ______ __________

( ) Dermatoses N/A ______ __________
( ) Infection as
folliculitis
abscess/paronychia ___1__ _____1____
( ) Others ______ __________

Head:

( ) Tension/headache 3 7___ 10
( ) Others ______ __________

Eyes:

( ) Error of
refraction N/A ______ __________
( ) Bacterial/Viral
conjunctivities N/A ______ __________
( ) Cataract N/A ______ __________
( ) Others ______ __________

Mouth & ENT:

( ) Gingivitis N/A ______ __________

( ) Herpes Labiales/
nasalis N/A ______ __________
( ) Otitis Media
Externa ___1___ ____1_____
( ) Deafness N/A ______ __________
( ) Meniere”s Syndrome
/Vertigo _4__ ___2__ ____6____
( ) Rhinitis/Colds 1 2___ _3
( ) Nasal Polyps N/A ______ __________
( ) Sinusitis N/A ______ __________
( ) Tonsilio

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 pharyngitis 2 ___2___ 4
( ) Laryngitis N/A ______ ____________
( ) Others N/A ______ ____________

Respiratory:

( ) Bronchitis N/A ______ ____________

( ) Bronchial/Asthma 1 _1____ _____2______
( ) Pneumonia N/A ______ ____________
( ) Tuberculosis N/A ______ ____________
( ) Pneumoconiosis N/A ______ ____________
( ) Others N/A ______ ____________

Heart and Blood Vessel:

( ) Hypertension 5 __4____ _____9______

( ) Hypotension N/A ______ ____________
( ) Angina Pectoris N/A ______ ____________
( ) Myocardial
Infraction N/A ______ ____________
( ) Vascular
disturbances in
extremities due
to continuous
vibration N/A ______ ____________
( ) Others N/A ______ ____________

Gastrointestinal:

( ) Gastroenteritis/
Diarrhea 1 ___5___ _____6______
( ) Amoebiasis 1 ______ _____1______
( ) Gastritis/
Hyperacidity ___1___ _____1______
( ) Appendicitis N/A ______ ____________
( ) Infectious
Hepatitis N/A ______ ____________

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 ( ) Liver Cirrhosis N/A ______ __________
( ) Hepatic Abscess N/A ______ __________
( ) Cancer (Hepatic/
Gastric) N/A ______ __________
( ) Ulcer N/A ______ __________
( ) Others N/A ______ __________

Genito Urinary:

( ) Urinary Tract
infection 2 2
( ) Stones N/A ______ __________
( ) Cancer N/A ______ __________
( ) Others N/A ______ __________

Reproductive:

( ) Dysmenorrhea 3 3
( ) Isfection
(Cervicitive)
(Vaginitis) N/A ______ __________
( ) Abortion
(Spontaneus) N/A ______ __________
(threatened) N/A ______ __________
( ) Hyperremesis
Gravidarum ___1__ _____1___
( ) Uterine Tumors N/A ______ __________
( ) Cervical Polyp/
Cancer N/A ______ __________

12. Immunization Program (Indicate number immunized)

Nature Male Female Total No.

Of Cases
Tetanus Toxoid Injection ______ __________ __________
Tetanus Antioxin Injection ______ __________ __________
Tetanus Globulin Injection ______ __________ __________
Hepatitis B Vaccine ______ __________ __________
Rabies Vaccine ______ __________ __________
Others (Please Specify) ______ __________ __________

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13. Keeping of Medical Records of Workers (Please Check)

() Done () Not Done

14. Health Education and Counseling by Health and Safety Personnel: (Please Check one
or more)

() done individual 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 Seminars Use of Visual Counseling

id/Materials
Nutrition Program ( ) ( ) ( )

Material and Child Care Program ( ) () ( )

Family Planning Program ( ) ( ) ( )
Mental Health Activities ( ) ( ) ( )
Personal Health Maintenance ( ) ( ) ( )

Physical Fitness Program: (Please Check)

Sport Activities () Yes ( ) No

Others (Please Check) ( ) Yes ( ) No

16. Hazard in the workplace : (Please check and give details of the substance)

Substance and/or Number of workers

sources exposed

a. Chemical Hazard:
b.
( ) Dust (Ex. Silica dust) N/A ________________
( ) Liquid (Ex. Mercury) N/A ________________
( ) Mist/fumes/vapors
(Ex. mist from paint spraying) N/A ________________
( ) Gas (Ex. CO, H2S) N/A ________________
( ) Others (please specify)
(Ex. solvents) N/A ________________

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 Physical Hazards

( ) Noise
( ) Temperature/humidity
( ) Pressure
( ) Illumination
( ) Radiation/ultraviolet/microwave
( ) Vibration
( ) Others (Please specify)

c. Biological hazard:

( ) Viral _______________ N/A

( ) Bacterial _______________ N/A
( ) Fungal _______________ N/A
( ) Parasitic _______________ N/A
( ) Others, specify _______________ N/A

d. Ergonomic Stress:

( ) Exhausting physical work _______________ N/A

( ) Prolonged standing _______________ N/A
( ) Low back pain _______________ N/A
( ) Unfavorable work posture _______________ N/A
( ) Static/monotonous work _______________ N/A
( ) Others, specify _______________ N/A

Submitted by:

Maria Eunisa M. Bitong/Company Nurse 01/31/2019

Medical Personnel/Title Date

Noted by:

ERNESTO P. VILLARUEL JR.

Employer