MEDICAL EXAMINATION REPORT

DATE OF EXAMINATION : March 24, 2021

COMPANY : PT.JUE MAN-HING INDONESIA
NAME OF THE APPLICANT : Mr. ZAINAL ARIFIN WIJAYAKA M ü F
PLACE / DATE OF BIRTH : BANGKALAN, March 10ᵗʰ 1996 NATIONALITY : INDONESIA
EXAMINATION FOR DUTY AS A : LAUNDRY VESSEL NAME : MS. PACIFIC VENUS
MAILING ADDRESS OF APPLICANT : DSN. DANGKOLOR RT/RW 001/001 PASSPORT NO.
KEL. BANTEYAN KEC. KLAMPIS
KAB. BANGKALAN PROV. JAWA C 7793533
PHONE No. : 085606368236 TIMUR

MEDICAL HISTORY (Check if any medical conditions listed apply)

YES NO YES NO YES NO YES NO
1. MEASLES 9. SHORTNESS OF BREATH 17. PEPTIC ULCER 25. SURGICAL HISTORY
ü ü ü ü
2. DIPTHERIA 10. SMALL POX
ü ü 18. CHEST PAIN
ü 26. NARCOTIC HISTORY
ü
3. TYPHOID FEVER 11. EAR DISTURBANCES
ü ü 19. SEIZURES
ü 27. ALCOHOL HISTORY
ü
4. LIVER DISEASE 12. NERVE DISTURBANCES
ü ü 20. KIDNEY DIASEASE
ü
28. SMOKING HABIT
ü
5. ASHMA 13. THYROID DISTURBANCES
ü ü 21. VENERAL DISEASE
ü
29. HYPERTENSION
ü
6. BRONCHITIS 14. FREQUENT HEADACHES
ü ü 22. DIABETIC
ü
30. LOSS OF VISION
ü
7. TUBERCULOSIS 15. HEART DIFFICULTIES
ü ü 23. RHEUMATISM
ü
31. LOSS OF MEMORY
ü
8. MALARIA 16. FRACTURE/DISLOCATIONS
ü ü 24. TUMOR
ü
32. HERNIA
ü
33. Have you ever been hospitalized ?
ü
34. Have you ever been declared unfit for sea duties ?
ü
35. Do You feel healthy and fit to perform the duties of your designated ?
ü
36. Are you on medication ?
ü
37. Are you allergic to any specific food, drugs, or other conditions such as weather ? (If yes give detail )
ü
38. Do you free from any medical condition likely to be aggravated by service at sea or to render the seafarers unfit for such service or to
endanger the health the of other person board ? ü
I here by permit by Shipping Company/Agency/Manning Agency and the undersigned physician to finish such information the company may need
pertaining to my health status I here by permit by Shipping Company/Agency/Manning Agency and the undersigned physician to finish such
information the company may need pertaining to my health status false statement will disqualify me from employment benefits and claims.

Signature of Examinee

P H I S I C A L E X A M I N A T I O N
HEIGHT WEIGHT BLOOD PRESSEURE PULSE RESPIRATORY BODY BUILT :
RATE
Reguler Poorly Developed Fairly Developed
170 60 120/70 62 18
x/menit
ü
Yes No
Well Developed
ü Overweight
x/menit Obese
cm kg mmHg
VISION COLOR PERCEPTION (ISHIHARA'S METHOD) HEARING NOTES/COMMENTS
VISION Without Glasses With Glasses Normal :
Colorblindness YES NO
RIGHT EYE 20/15 YES ü NO Right Ear
LEFT EYE 20/15 (If yes give detail) ü
Left Ear
BOTH EYE 20/15 ü
Normal Normal Normal
YES NO YES NO YES NO
1. EYES 8. LUNGS 8. SKIN & NAILS
ü ü ü
2. EARS 9. HEART 9. SPEECH
ü ü ü
3. NOSE 10. UROGENITAL SYSTEM 10. HERNIA
ü ü ü
4. MOUTH 11. UPPER EXTREMITIES 11. ABDOMEN
ü ü ü
5. THROAT 12. LOWER EXTREMITIES 12. SCAR
ü ü ü
6. THROID 13. BACK ABDORMALITY 13. REFLEXES
ü ü ü
7. LYMP NODE 14. CENTRAL NERVOUS SYSTEM 14. OTHER
ü ü ü
Serving : Medical Check Up Seaman, Indonesia Labour, Laboratory, Rontgent, ECG, and Medication of Public
COMPANY : PT.JUE MAN-HING INDONESIA
NAME OF THE APPLICANT : Mr. ZAINAL ARIFIN WIJAYAKA AGE : 25 Years Old
LABORATORY FINDINGS
BLOOD TEST URINE ANALYSIS
HEMATOLOGY, BLOOD CHEMISTRY, SEROLOGY / IMMUNOLOGY SPECIFIC GRAVITY : 1.020
HEMATOLOGY PROTEIN : Negative
Hb : 14.5 gr/dl GLUCOSE : Negative
WBC : 6600 /uL UROBILINOGEN : Negative
TROMBOSIT : 302000 /uL BILIRUBIN : Negative
DIFF COUNT : 2 / 0 / 1 / 65 / 27 / 5 % MICROSCOPIC : WBC : 0-2 /hpt
ESR : 2 mm/jam
RBC : NIL /hpt
PCV : 41 %
RBC : 4.4 juta/uL CAST : Negative
MCV : 90 fl CRYSTALS : Negative
MCH : 31 pg BACTERIA : Negative
MCHC : 35 g/dl COLOUR : Yellow
BLOOD CHEMISTRY
SGOT : 19 U/L
SGPT : 24 U/L
GAMMA GT (GPT) : N/E URINE TESTING FOR ALCOHOL & DRUGS OF ABUSE
GLUCOSE (fasting) : 96
(2 hours after meal) : 107
ALCOHOL : Negative
(ad random)) :
TOTAL CHOLESTEROL : 158 mg/dL AMPHETAMINE : Negative
HDL CHOLESTEROL : 42 mg/dL MORPHINE : Negative
LDL CHOLESTEROL : 120 mg/dL THC : Negative
TRIGLYCERIDES : 173 METAMFETAMINE : Negative
UREUM : 29 mg/dL COCAIN : Negative
CREATININE : 1.0 mg/dL
BENZODIAZEPINES : Negative
URIC ACID : 4.8 mg/dL
PROTEIN TOTAL : 6.8 g/dL
BILIRUBIN TOTAL : 0.28 mg/dL
ALKALI PHOSPHATES : OTHER DIAGNOSTIC TEST

SEROLOGY/IMMUNOLOGY Chest X - RAY Report : Normal

VDRL (RPR) : Non Reactive

TPHA : N/E ECG : Normal
HIV : Non Reactive
HAV : Non Reactive
HBsAg : Non Reactive AUDIOMETRI : Normal
HCV : N/E
HBeAg : N/E
SPIROMETRI : Normal
Anti HBsAg : N/E
STOOL ANALYSIS
TREADMILL TEST : N/E
WBC : 1 /lpk
RBC : NIL
PARASITE EGG : Negative USG ABDOMEN : N/E
AMOEBA : Negative
FAT : Negative
BLOOD : Negative
FIBER : Positive
AMYLUM : Negative
COMMENT ON MEDICAL HISTORY AND CLINICAL EVALUTION :
The abovenamed person physically : JAKARTA, March 24, 2021
ü Fit
Fit with minor correctible defect
Has mayor physical defect, fit with restriction for
selected assiggnment
Unfit
For duties on board ship
Doctors Advice : NAME & SIGNATURE OF
THE EXAMINING PHYSICIAN
Early Detection Is Important For You To Get Healthy Life
Name : Mr. ZAINAL ARIFIN WIJAYAKA Company / Agent : PT.JUE MAN-HING INDONESIA
Age : 25 Years Old Date : March 24, 2021
Sex : Male Lab. Number : E-210324-001155
Doctor : dr. Raymond Ferdinand Runtu, Sp.PK Identity Card : C 7793533

LABORATORY TEST RESULT REFERENCES RANGE SET OF REMARK

Golongan Darah / Blood Group
Blood Type A
Rhesus +
Hematology
ESR 2 < 10 mm/jam
Hemoglobin 14.5 13.0 - 18.0 gr/dl
White Blood Cell Count 6600 5000 - 10000 /uL
Hematocrit / PCV 41 39 - 54 %
Red Blood Cell Count 4.4 4.3 - 5.5 juta/uL
MCV 90 80 - 93 fl
MCH 31 26 - 31 pg
MCHC 35 32 - 36 g/dl
Trombosit 302000 150000 - 450000 /uL
DIFF COUNT
Eosinofil 2 1-3 %
Basofil 0 <= 1 %
N. Batang 1 1-3 %
N. Segmen 65 20 - 70 %
Limfosit 27 20 - 50 %
Monosit 5 0-8 %
IMUNOLOGI
HBsAg Non Reactive Non Reactive
Anti-HCV Non Reactive Non Reactive
Anti-HAV
Anti-HAV Non Reactive Non Reactive
VDRL Non Reactive Non Reactive
Anti HIV Non Reactive Non Reactive
KIMIA KLINIK
Natrium 137 138 - 145 mmol/L
Kalium 3.8 3.5 - 5.1 mmol/L
Kalsium 7.8 8.0 - 10.5 mEq/L
Phosfor 3.6 2.6 - 4.5 mg/dL
Ureum 29 19 - 44 mg/dL
Creatinin 1.0 0.7 - 1.3 mg/dL
Asam Urat 4.8 3.6 - 7.9 mg/dL
Urea N (BUN) 15 Usia < 1 thn : 4-19 mg/dl
usia 1-17 thn : 5-18
usia 18-60 thn : 6-20
usia 61-90 thn : 8-23
usia > 90 thn : 10-31
SGOT 19 0 - 35 U/L
SGPT 24 0 - 41 U/L
Bilirubin Direk 0.09 0.1 - 0.3 mg/dL
Bilirubin Indirek 0.18 0.1 - 1.0 mg/dL
Bilirubin Total 0.28 < 1.1 mg/dL
Fosfatase Alkali 3.6 98 - 279 U/L
Albumin 4.8 < 6.0 g/dL
Globulin 2.0 < 2.9 g/dL
Protein Total 6.8 6.0 - 7.8 g/dL
Glukosa Sewaktu < 140 mg/dl
Glukosa 2 Jam PP 107 < 140 mg/dl
Glukosa Puasa 96 70 - 110 mg/dl
CK-MB 5 < 24 U/L
Cholesterol 158 < 200 mg/dL
Trygliserid 173 125 - 200 mg/dL
HDL 42 30 - 75 mg/dL
Name : Mr. ZAINAL ARIFIN WIJAYAKA Company / Agent : PT.JUE MAN-HING INDONESIA
Age : 25 Years Old Date : March 24, 2021
Sex : Male Lab. Number : E-210324-001155
Doctor : dr. Raymond Ferdinand Runtu, Sp.PK Identity Card : C 7793533

LDL 120 66 - 178 mg/dL

Name : Mr. ZAINAL ARIFIN WIJAYAKA Company / Agent : PT.JUE MAN-HING INDONESIA
Age : 25 Years Old Date : March 24, 2021
Sex : Male Lab. Number : E-210324-001155
Doctor : dr. Raymond Ferdinand Runtu, Sp.PK Identity Card : C 7793533

LABORATORY TEST RESULT REFERENCES RANGE

STOOL ANALYSIS
WBC 1 <3
RBC NIL NIL
PARASITE EGG Negative Negative
AMOEBA Negative Negative
FAT Negative Negative
BLOOD Negative Negative
FIBER Positive Positive
AMYLUM Negative Negative
Name : Mr. ZAINAL ARIFIN WIJAYAKA Company / Agent : PT.JUE MAN-HING INDONESIA
Age : 25 Years Old Date : March 24, 2021
Sex : Male Lab. Number : E-210324-001155
Doctor : dr. Raymond Ferdinand Runtu, Sp.PK Identity Card : C 7793533

LABORATORY TEST RESULT REFERENCES RANGE

Narkoba / Drug
Amphetamin Negative Negative
Cocain Negative Negative
Opiat/Morphin Negative Negative
Alkohol Negative Negative
Morphine Negative Negative
THC Negative Negative
Metamfetamine Negative Negative
Benzodiazepines Negative Negative
Urinalysis
Chemical Analysis
pH 6.0 5.0 - 8.5
Protein Negative Negative
Glukosa Negative Negative
Urobilinogen Negative Negative
Bilirubin Negative Negative
Keton Negative Negative
Microscope Analysis
Eritrosit NIL NIL
Lekosit 0-2 <3
Cylid Negative Negative
Epith Cells Positive Positive
Bacteria Negative Negative
Crystal Negative Negative
Specific Gravity 1.020 1.000 - 1.030
Colour Yellow Yellow
 SEAFARER MEDICAL FITNESS CERTIFICATE
No. E-210324-001155 / PG / PT.JUE MAN-HING INDONESIA / OLMC / III / 21

DETAILS OF SEAFARER

Full Name : Mr. ZAINAL ARIFIN WIJAYAKA

Place & date of birth : BANGKALAN, March 10ᵗʰ 1996
Nationality : INDONESIA
Shipping Co./Manning Agency : PT.JUE MAN-HING INDONESIA
Job Position / Rank : LAUNDRY
Vessel Name : MS. PACIFIC VENUS
BASIS
The medical examination which cover Medical fitness, Visual system and Auditory system has been
performed and it was found that the result complies with the Medical standar of

ü State Flag of INDONESIA

Current ILO / WHO

ü Principal

CONCLUSION
On the basis of the above examinee’s personal declaration, medical examination and diagnostic test
result recorder in the attachment; I, hereby certify that the above examinee is medically
........................................................LAUNDRY......................................................................
DOCTOR INDICATION & SPECIAL ATTENTION ON AT WORK

VALIDITY
Valid From : March 24, 2021
Valid Until : March 24, 2023
Area of validity : ü No Restrictions
Restricted due to.....

Place of Issue, Jakarta, Indonesia

Medical Review Officer

Note: This certificate does not cover diseases that would require special procedures and examination for their detection
Such as, Bronchiectasis, wich need bronchography ; Pectic ulcer/gall bladder diseases which need cholecystograhy,
Endoscopy,etc, kidney problems which need IVP and also those which are asymptomatic at the time of examination
including psychological test and other which not cover by the above mentioned standard.
 DENTAL CHECK UP REPORT
Name : ZAINAL ARIFIN WIJAYAKA Company / Agent : PT.JUE MAN-HING INDONESIA
Age : 25 Years Old : March 24, 2021
Date
Sex : MALE
PG. Number : E-210324-001155
Doctor : drg. Indriyani Komalasari

CHIEF COMPLAINT
FINDING :

1. TEETH MISSING

2. CARIES TEETH

3. PERIODONTALLY INVOLVED TEETH

4. OTHER : CALCULUS+++, PRO SCALLING

ADVICE :

DENTAL HEALTH CERTIFICATE

No. E-210324-001155 / PG / PT.JUE MAN-HING INDONESIA / OLMC / III / 21

THIS IS TO CERTIFY THAT I HAVE EXAMINED : Mr. ZAINAL ARIFIN WIJAYAKA

AGE : 25 YEARS OLD SEX : MALE
AND WAS FOUND HIS / HER DENTALLY FIT
 CERTIFICATION
DRUGS AND ALCOHOL TEST

Ref No. : No. E-210324-001155 / PG / PT.JUE MAN-HING INDONESIA / OLMC / III / 21

Company/Agency : PT.JUE MAN-HING INDONESIA
Date : March 24, 2021

FULL NAME : Mr. ZAINAL ARIFIN WIJAYAKA

RANK : LAUNDRY
SEX : Male

AGE : 25 Years Old

Was examed for the presence of the following drugs and alcohol in the urine using the
Compotitive Immonoassay/Chomatographic Absorbent Method and was found :

Amphetamine : Negative
Morphine : Negative
THC : Negative
Methamfetamine : Negative
Cocain : Negative
Benzodiazipenes : Negative
Significant Alcohol Level in Blood was : Negative

Jakarta, March 24, 2021

Medical Review Officer

 CERTIFICATION
ANTI HIV TEST RESULT

Ref No. : No. E-210324-001155 / PG / PT.JUE MAN-HING INDONESIA / OLMC / III / 21

Company/Agency : PT.JUE MAN-HING INDONESIA
Date : March 24, 2021

FULL NAME : Mr. ZAINAL ARIFIN WIJAYAKA

RANK : LAUNDRY
SEX : Male

AGE : 25 Years Old

ADRESS : DSN. DANGKOLOR RT/RW 001/001 KEL.
BANTEYAN KEC. KLAMPIS KAB. BANGKALAN
PROV. JAWA TIMUR
Is : NON REACTIVE

This Is To Certify That The Test Is Correct And True

Jakarta, March 24, 2021

Medical Review Officer

 BAGIAN AUDIOLOGY / THT AUDIOGRAM : SIEMEN

500 1000 2000 4000 Nama : Mr. ZAINAL ARIFIN WIJAYAKA

0
Umur : 25 Tahun
D E C I B E L S

10 Alamat : DSN. DANGKOLOR RT/RW

001/001 KEL. BANTEYAN
20
KEC. KLAMPIS KAB.
30 BANGKALAN PROV. JAWA
TIMUR
40 Perusahaan : PT.JUE MAN-HING
H E A R I N G

INDONESIA
50

60 SPEECH TEST
I N

70

80
L E V E L

90 PEMERIKSAAN KHUSUS
100

110
500 1000 2000 4000
FREQUENCY IN HEARTZ ( Hz )

Udara Tulang
Dibuat : OLMC
HANTARAN TULANG Kiri : Merah X Oleh :
HANTARAN UDARA Kanan : Biru O
Tanggal : March 24, 2021
^ Masking
Telinga Kanan ( AD ) : Normal
Telingan Kiri ( AS ) : Normal
Dokter Pemeriksa