Permintaan Evaluasi Kelaikan Kerja Kontraktor F_OH_017 BAGIAN A. _Identitas Karyawan (disi dengan lengkap oleh karyawan) Nama Lengkap Tanggal Lahr (gl - bln thn) | Jenis Kelamin Robert Wiliam Lobo 2aNay 1965 Ditokiteki CO) Perempuan Pekerjaan (Job Title) ‘Nama Perusahaan Lokasi Kerja] Onshore - ___ Rig Superintendent PT. COSL INDO Oofce §K] Ofshore ‘Alamat Rumah ‘Nomar Telepon / HP ‘Tanggal Pemeriksaan (tgl - bin - thn) 3204 BRIDLE LANE, GRAPEVINE, TEXAS-76051, USA. | 0813858605374 16 November 2021 BAGIANB. —_Alasan Evaluasi (diisi dengan benar oleh supervisor / bagian kesehatan perusahaan kontraktor) Beri tanda pada kotak yang sesuai Z._Pemeriksaan sebelum bekerja (Pre-placement), untuk kategor posisi Cl sedentary Worker] Non-sedentary Worker onshore 0 & Gas Worker] Offshore 01 8 Gas Worker Oserurt Li Fire Emergency Responder Team — ["] Driver Mobi Perumpang (—] Operator let Berat CoPenyelam Diver =) Kru Kapal O Pilot 1 Food Handler Tenaga Kesehatan] Petugas Sampling / Laboratorium [] Awak Mebil Tank (]_ Pemeriksaan berkala (Periodic), untuk kaltegori posisi: D1 Sedentary Worker (Cl Non-sedentary Worker Ci Onshore Oil & Gas Worker —[X] Offshore Oil & Gas Worker Dsehunt Fire Emergency Responder Team [] Driver Mobi Penumpang _(_] Operator Alt Berat CPenyetam/ iver) Kru Kapal Pie 1 Food Handtor Tenaga Kesehatan CJ Petugas Sampling / Laboratorium — (_] Awak Mobil Tanki ( Retum to Work Tidak masuk kerja 2 14 hari kalendar karena sakt atau cedera, atau < 14 har jka Kondisi medis dna serius, atau diturunkan ‘saat masa on duty. O For Cause: (1 Paska Insiden (1 Supervisor menyangsikan kelaikan kerja pekerja 11 Job Transfer Dilakukan sebelum pemindahan tugas ke posisi ain. Komentar Supervisor (sebutkan tambahan pekerjaan lain atau faktor risiko di tempat kerja bila ada): Kertralor (201Lampiran 4 - B7-004/kT1210/2019-S9. “F_OH_018_Formutir Evaluasi Contractor Fitness To Work spdur CFTW: [] Pre-Placement JX Periodic] Retum to Work (] For Cause (] Job Transfer ae Tanggal Lahir (gh eer witiam Leto MY 23,1965 Staite | OpPerempuan Pekerjaan (Job.Tiley 7 NamaPenisahasn Lokasi Kerja [TOnshore: OFFSHORE ISTRATION 11 OOffce _-- se oftstore ‘amat Ruta “Tanggal Pemerisaan (ql—bin Win) ARIK in aiyewant| ic Medical Gheck Up terakhir, apakah And Tidak, 2 TY t TTY + | Nepal osaroldceins | O11] $8. | Resalektyengtaaiton |S ETT a Sali lau codera eer tan a pretrial tangadocan sar deng belekang q 2. | Ganggian mata ata SYD | 14 | Pesala ein ainng [A] ED | 25 | Pata tang, wit, dete ajo pours dp hae, Pabpltasijenting berieber ‘mold “ , ‘ Dysttarateriekan aan. ‘ ‘erbekar pia data w 15. | Anemiataxsng darch wl Nved send remat tel} i aan CO] 16.7 Perattmsag taggin | [| 28 Mogan ea io wo] a. 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PT Rg Hazard a era: (2 Bising (J Getaran (] Benzene: PBahan Kiera. wns ES) Lapa on va a aging saad onda var == Poe zs lesan wala etnpe Sai apet SSSR ttn ara ae Samoan ong eee Tia Porn RSE fanda Tangan Kagyaaran Cr a qi [ (Aoltbe MVIS OU donut a DIDI Fe Bod ad ea mat 2629 :DENYUT NADL 62 ~ximt Foran txgetVO2 max: 30 ~ 42 mish, Schur frgetVO2 max: 4—A2mlsghnn, ONT SEN DADA 1 fia C1 Tak ioral flake: tktak sedang dalam kondis! fulpiles + Fitto WoricFiiman fk hasl spromet FEV! dan FC <@0%, Aree 3) hanus dlovelués} dengan perhitungan LLN Preumobile aaiee Jadionesiat DTidek mendicita TB Keceagaa? “ = CiNomal [) Thisk Normat ObstnikfRestixt. Catalan: *) asl evaluasi LL: NamaPomeriksa - Tanda Tangan Pemeriksa Tanggal Pemeriksaan Standard: = Mrimalvays 246 unt river dangat aa anpa aca erst une eatap mat * Lapanen pando horizontal minimal 702 paca masing-tieg ma nik rher dan Crane Operator { Dapatinengengt stat membedakan wares tmp) peng laht Kas (Mra, Kung dat Ht) 1 Bua ea mata DAK quod uric + Keoa ala nicer ager locus dla Medal Clearance Tampa Karta Soran ou ula Wana —[ Lapa Pandang Kijdna Mata | Mata Kanan | Mata Kit | Koda Mats |- Asta Kanan | Mata Kirt : Kanan are] un (2 [aw a y= Pan woe FleteWameTotd | rats Nototall soemn Lora Lets, |e ais [oe wb lug Freivann esas ee “eink Dekat | By 2. S19 [5x [ase = [ge Kesipitant Kaj Wormat (faba Recmnatn (Tie Paalkalerats (2 Week onal Gocaiea Catatan: i Haina Pemertksa “Yenda Tengen Pomeriise | “Fanggal Pemetticsaan Hanigah func 164 Leet 2 eet Ente tek Masonite! 8)Lampiran 4 - B7-0041KT4240/2019-S9 Standar: ; ‘ Depatnndongy aura dak > 165 mtr denn lau apa lt ant soa ose ATAL + Ratneia penuh ha paneer paca tig yang tbl 4 3 dangan stan tampa mergguntan lt ant dong Menggunakan al lta dengar? (Ya. (A Tidak 3 TesBebic | Tenge Kanan. rst Telnga meter Audiometrl (dB. . Tanga Kid Talinga Kenan i | [| sn [we [oe | [| me [ [ao |e [om ws | PE | IS |25] 30 | ssltool4| | last calostis lel ssleo Ambang denger rita | Teinga Kid ...00...€8 _Telinga Kanan « @ \ esimpolan: CTWemmat 1 Tak Herma jlkan— AD > yy py I j on Fee ‘Natha Pemeriksa ‘Tanggal Pemeriksaen 16 > 2024 Mn z.| Pemerikssan anal hitung dara Tenghap: Hb, Eibos, Leukbs, Hung Joni, Hemateii, ‘Trambost, LED, Rid Cell Indices (MOV, HCH, | MCHC) si __ | Panel Kiria dara «| « Profi Upit Tee Kcleteey, den. petit © Funge Hall: Total biinibin, Direct & indirect Blin, SGOT, dan SPT 1 Fangs get tn trl eum dan tesa, Cada dara pea Cul dara 2jam each mln Une Anais lengkan Kultur Feses (asus unt food hendler) No | Bagian + Kensta ‘aaa coda ¥ : Te eter re Retnope ataree sfn, sores : ‘Sogonorad masse (rte Chana en 7] Pengarsna a = penylenbalan kanal cera, pvr . e a a +o ling daa "| pemaanan ‘snes soto ae v Parntcnan tation spat od peel ea) commer ;| 01 A-Memenuhi Syarat, masa berlaku: C} 6 bale (4 tahun Lampiran 4 - B7-004/KT1210/2019-S9 iz 1 B.Memendti Syarat Dongen Catatant 4 2 3 ght wk 2 sual as Ww ot a pea br A "na Taner aa cn ing, pans | nunc dat pce fring, dar plan, pe ee, cara v T | Rodan d feletat ces claereoacd ang | an iddamaya elemahan dindng abdomen yang bermakna |_|” 8 | Tideng| (dan Hdatnaraopeas xia ttn kd lean v | Pereraian (ROM), keckifan snonota 3 | Silom Hema 7 70 | Ekta faopan Rehan Teng i Joma al eae, dental) Jemad nga telson bens stpy, Fleer n 2 conga, atisena idan ilaen bgt ” nas - stir, onto ene aa ld WT | Persjatan Ganga Hosea, Looe ican, ebakiesa | smi Aboermat ings seatpost, seciaefck ¥ | pateBabinky : Lekuan tes Romberg untk pele dl kainggion, contoh: scaffold, inspector ing _ 12 | Kuill dan kelajergetah | Dermelifa:ocabées,eksim, jeraal v ening’ é Berjolan parla lehes, hetiak, pangkal paha 3 | Tuner dn kegirasan | Agaryabercen yang 6d noma, Kenan yagmengaah 7 ke kegenacen TT | Penaren te Bese, tak rel Zz Eo : ‘Khwsus untuk Fooy Handler : Panag ie, i paid ES, a ed i heir ¢ Oi cere corny . Kata ( td aH : wm, MH, a Wun 8 Hbsheael TH C.tidak Wajmenunt Sy Gatatans Te cee Ei Perino | (of ementare avanea et: nao. ‘Clie mangginatan toca mata : Satan dae - 1 Marus manggunlan slat bonts denger a Baar Pas — Tanta Tom A naar ary Trt Age Wadi : 1-1-2021 brisnomr 7 Aaa Bais mY Ste send Sedteman Ho-2 + Balt Rs. Portamicia Battepapan "_ |eips omic tease 2’ Baltkrapan III EOL BEEING ERSLampiran 5 -B7-004T1210/2019-S9 F_OH_019_Resume Evaluasi Kelatkan Kerja Kontraktor Tanga Lat (f—Bir~Cn) | Jers Klann 7 Tebat te williqan, Lobe! 2305-1966 | Wai Nama Perusahaan CFTW Procedure . 11 Pre placement ha Periodic C] Retin to Werk (1 Fer Causo 7] Job Tranefoe. oat Keya:' DPerempuan Clones 5 onshore . Worehace *Posisi Utama: . ~ D1 Setentary Worker don-sedentary Worker D onshore 09 & Gas Workor D1 Offshore OW & Gas Worker Osea | DiFte ememency Responder Team, 2 Diver Motil Penumpang D Operator Alet Borat Cipenjelam aie xa Kapa 1 Piet 2 Food Handler Ci TenagaKesshatan 7 Petigas: ‘Sampling Laboratorium — (C] Awak Motil Tank Posisi Tambahan; ro He fORRESS i g he ee foku: [YS bilan (1) 4 tahun TGLMCU: ©» . oO A Memenubi Syare, masa JAB Meerut Syarat Dengan Catatan loggufbuln *[ Rekomendasi (ik. dipertukan tindak anf): Hama Deiter Poniatiiea = TY DEM SAiT ia] 16-252). 1a Fa RAPA 2 Par fed Qateman OT Battpapaw ts. Rtomina Baticpapan Tep-Oc74020 anus dilekukan vericast CFTW oleh HEM PHICT ume > = Palace dongen kon li tal yarn tl tama banat naan (web fetta twang atten Spree) eek Mea taeda, operct adr hs mc pcan am Sse engi, ere “= Pentamat makers (ed hana) dan Tenaga tats (Health Core Worker Persetuluan Heaith Macioal(gunakan hurat calak) ‘Yanda Yangon ‘Tanga! (BEMIS) naam . FLOM DIR Rene avs! Contacte PEcen io We (220)Lampiran 7 ~ B7-004KT1210/2019-S9 F_OH_021- Persetujuan Nlembuka Informasi Medis *: Saya yang bertanda tafigan di bawah ini: : . Nama oy fomoier Wie aw Tanggal lahir : 9S F-19605" Pekeyjaan 5 Pouschaan : Apexrndy. : Nomor Pogawai_: Alamat Nomor Telepon ” -: ri Dengan akél yang seh dan tanpa paksaan dari pak manapun, maka dengan ini saya memberiken kuasa kepada: Rumah Sekine =: spn.” Mama =" + Se level Gidicmen Ho-1 Bonkyayen _Nomor Teleport :_0S42~ 324020 . Untuk membukainionnasi medis saya, yang meliputi informasi di |bawah Ini (bisa pilih lebih dari satu); ~ gfe Catalan meds lengkap (C)Pemeriksaan laboretorisn [| Pamerikeaan mata (1Pemariksaan Fisik +” Spiromesi Audometi —__[C] informas! penyaioedera OlLeporan x Ray *ClAuciogram _ CEKG of (D1 Lainnya (mohon dijetaskan an " Selanjutnya ‘nformasi tersebut dapat diberikan kepada pihak-pihak berikut, = Nama ¥ Pertsahaan/instansi Aamat Nomor Telepon * Nama Foruschaaivinstansi ‘Alamat z . 2 NomorTelepon : . _ Unlok kepertuan (phon detaskan): ‘Saya memahami kecuali caya menjelaskan secara spesifik Informas! yang diungkapkan termesuk tapi tidak terbatas pada oe ipa nen ee ners paseo hg Sorter eorams t ; * Betetvngan dan urra ten glaurano talon soar laavan stot an coat ta aye ea ‘Acquired Immune Deficiency Syndrome (AIDSY. . Saya mengsjukari permintaan salinen dari lembar persetujuan inl: [] Ya [] Tidak" * . ‘ enh co 1) bor CRSA lc we ranaos NOY Hi 22! ats En= - es ‘Tanggal vende Verda Tengen Salat —{ —Hobungas Dengan Pemba wWanenang Tal BR= Thay FLOH.024_Pareekijuan Meme Inkoras! Mec 2018)eile, PERTAMEDIKA PERTAMINA BINA MEDIKA RS PERTAMINA BALIKPAPAN. HC Indonesia Healthcare Corporation Medical Screening Questionnaire (Surname: _LOB® Forename: POBERT WIC AM Address = Sloe BRIDLE Lore Geereving 7 |TelNo: +1 682 70y 2t7y [Date of sine ripe 2196S | laps Name: 1 [GP's Address: [Date of Last Offshore Medical: 3 EPF 20 -— Pe Emergency Response Role: _oveswete INGPRUATLETS [Sahara Oceupaiion/iab Titer @PRBTELE Wok Tah ee nae Social/Occupational History ‘Comments 1. Do you smoke? If so, how many per day? 2, Ifan ex-smoker, when did you give up 3. Average weekly aicohal consumption: state quantity and type. Have you ever been exposed to any known ‘occupational hazard such as,noise, radiation, duts, asbestos, chemicals or leda Nee ) CRMC, Pebiarien . Do yau use protective clothing, safety glasses or hearing protection ? AT wrowye OPESMORE CMILY Ig. Viave you ever developed any medical condition in| LISI AP ez aecvnation? so, please give Mlccdis eg Néaring loss/skin concition/wheere/ backache/muscle strain/blood disease ? 8 7. Have you ever suffer please give details ed any Industrial Injury? If's0, Have you ever had any previous audiometic Screening? Was this normal? State when and where dome Cots OF OREN G IN MDa’ LOFT Etre IS. Have you ever hiad previous lung function screening? Was this normal? State when and where. jis 86% toto AGPR Ps P6 110, Have you ever been rejected from employment on medical grounds? Ti, Have you ever re indusrtrial claim pending? ‘eived compensation or is there any Fiz, Have you ever been medivaced from an offshore Installation? Examining physician's comment Rumah Sakit Pertamina Balikpapan 4k. Jand. Sudirman No.1 Balikpapan, Kallmantan Timur 7611 7 : (842) 734020, 734021 F : (0542) 786154 E-mail: repb@rspblePERTAMEDIKA PERTAMINA BINA MEDIKA RS PERTAMIMA BALIKPAPAN IHC Indonesia Healthcare Corporation a : Medical Screening Questionnaire Bo you have or have you been diagnosed as sulfering from any of the following? (please circle and elaborate it Ehest pain/heart pain Yes Ge) 2. High blood pressure/stroke Qed | No | eaters I Gee [3: Asthma/epllepsy/diabetes Yes ®)y Ia. Peptic ulcer disease Yes (io) 5. Kidney disease (eg Stones) Yes >) 6. Psychiatric disorder (eg anslety, depression) Yes 7. Tuberculosis Yes | (No) | Rcancer Yes (wey) 5 [Do any of your immediate family (parents/brothers/sisters) have a history of any of the above conditions? Please specify: _ NO_ * [Do you currently have any of the following? z 2. Backache/joint or muscular pain ¥ AVE rhia/Reiptore "7 + [B._Visual impairment la. Perforated eardrum/discharge from ear 5. Recurrent indigestion [6. Jaundice/hepatitis/gall bladder disease 2 8 Pienaar: z Change in bowel habit/diarchoes - a ._ Blood in stools/piles/haemorrhoids (9. Shortness of breath/eoughing up blood [10 Recurrent bronchitis/pneumonia Yes 3. Blood in urine kidney compllcatlons/ one Yer 12! Headaches/migraine/sissiness ves Physician's comments: | certivy that the above Information Is correct: ~ t B/S. a RA, [employee] Rumah Sakit Pertamina Balikpapan 4, Jend. Sudirman No. 1 Balikpapan, Kalimantan Timur 7611 Ts (0542) 734020, 734021 F : (0542) 736134 Femail: reph@repb.idIndonesia Hes!thcare Corporation MEDICAL CHECK UP REPORT Medical Check Up has been done to: NAME ROBERT WILLIAM LOBO, Mr ey lta 2 \HC GENDER [i Ae Male 56 y/o ‘COMPANY COSLINDO. PT JOB POSITION Rig Superintendent EXAMINATION DATE") 16 November 2021 MR NUMBER, 10040923 Physician Examination Result Q COMPLAINT None Sinusitis, low back pain, hypertension, hepatitis (jaundice in 1997), hasmimoto disease SURGICALHISTORY // Appendictomy in 1995 HOSPITALIZED HISTORY None MENSTRUATION HISTORY | None HEALTH HISTORY SMOKING STATUS None ALCOHOL CONSUMTION® | None MEDICATION Levothyroxine, Metoprolol, Atorvastatin, Aspirin SPORT Walking FAMILY HEALTH HISTORY! Asthma (brother), Hashimoto disease (brother, sister) VACCINATION HISTORY —_Covid 19 (2x), Yellow fever, MMR, Polio, Tetanus, Hepatitis A, Typhoid HAZARD EXPOSURE!" | Noise, Chemical toxic, Radiation i PHYSICAL RESULT — waist BODY MASS BLOOD PRESSURE HEART RATE HEIGHT WOGHTS) | s@eaPnce. se 100/60 mmHg 62 x/minute 170m athe 207m (Overweight (29.2) HEAD EVES: EAR, NOSE, THROAT Normal ‘Normal, wearing glasses Normal ‘TEETH & MOUTH HEART LUNGS | Unexamined Normal Normal ABDOMEN, HERNIA ANUS & RECTUM, GENITOURINARY Normal Normal Normal MUSCULO SKELETAL NEUROGICAL SKIN | Normal Normal Normal | Rumah Sakit Pertamina Balikpapan Jt, Jend. Sudirman No. 1 Balikpapan, Kalimantan Timur 7611 T: (0542) 734020, 734021 F : (0542) 736134 E-mail: rspba@rspb.id Web: www.tspb.id| ap Eps — | ECG Sinus Rhytem, LAD, LVH, LV Strain ‘TREADMILL TEST ‘AEROBIC CAPACITY BODY FIT LEVEL Borderline stress test 13.10 Mets Good JAKARTA CARDIOVASKULAR SCORE High risk (cardiovascular risk > 20%) ‘CARDIOLOGIST EXAMINATION = CT Coronary Angiography : Mild vessel disease = Conclusion : Fit to work in remote areas / offshore @ EOS AvoD vos. ‘ApDc Vision _ megs SSS" 85 o ° 6/758-0,25 > 6/6 $+250 | TONOMETRYOD — TONOMETRY OS ‘COLOR BLIND TEST CONFRONTATION TEST | 12 mmHg 14 mmHg Normal Normal | OPHTHALMOLOGIST EXAMINATION | SAODS : Within normal limits. ODS : Normal fundus J [as Een nae ABNORMAL RESULT Glucose fasting 175 mg/dl, Glucose 2 hours pp 242 mg/dl, Gamma GT'57 U/L, Uric cid 8,1 mg/dl, Urinalysis : Bacteri 11 [PK > Glucose random 214 mg/dl, HBAIC 8,40 % RADIOLOGY RESULT — , | CHEST X-Ray cor mR SINUS & DIAGFRAGMA Heart shape & position normal «50% Normal PuLMO wes SOFT TISSUE & SKELETAL CONCLUSION Pulmonary structure is normal and shows var normal normal vascular markings Normal The hace agp : CoE SS [aera uspek Tatty Hver Gallbladder, pancreas, kidneys, spleen and urinary bladder are within normal limits Pe ENTSPECIALIST EXAMINATION] le AS: conductive heating a tnd sre wnieannanpldmpertarninn Bamapen loss JI. Jend. Sudirman No. 1 salicpapan, Kalimantan Tut 76 140542) 724020, T3402 F (0542) 736134 Email repbQrepb id Web www sspbidFERTAMINA BINA MEDIA, af, | PERTAMEDIKA IHC Indonesia Healthcare Corporation Diagnose : DM . Therapy : Janumet Noes Url) ‘Conclusion : Fit to work ~ Low purine, low sugar and low calorie diets Reduced body weight until 72 kg Undergo laboratory examination HBAIC every 3 months Consult to internist to treat DM, hyperuricemia, hashimoto disease and fatty ver Undergo vaccination of hepatitis 8 booster ‘Wear earplug properly in noise areas Balikpapan, 16/11/2021 Examining Physician, L dr. Tri Suji Wati Rumah Sakit Pertamina Balikpapan Jt. Jend. Sudirman No. 1 Balikpapan, Kalimantan Timur 76101 Ts (0542) 734020, 734021 F : (0542) 736134 E-mail: rspb@rspb.id Web: www.rspb.ida PERTAMEDIKA, BEA Nama Tanggal lahir Jenis Kelamin Dokter Pengirim Alamat LABORATORIUM KLINIK RUMAH SAKIT PERTAMINA BALIKPAPAN : Robert William Lobo, Mr 23-05-1965 + Laki-laki = TRISUSI WATI, DR. : PT. APEXINDO BALIKPAPAN IHC — Eorporation | Nomor M.R 10040923 Order No. :2111160106 Tangeal/Waktu : 16-11-2021 9:47:48 AM Ruangan = MCU RSPB Telp. + 410258 EXT.202/0827042274 Tanggal Cetak: 16-11-2021. 3:15:00PM Page 1 of 3 Nama Tes Hasil Flag Unit Normal Keterangan Hematologi ae Hemoglobin 154 e/a 140-180 Hematokrit 439 * 420-520 Eritrosit 517 s0%6/ul 470-6.10 Lekosit 787 10°3/uL 480-1080 Trombosit 24 10"3/aL 150-450 macy 85 ft 81-99 McHe 35 e/a 33-37 MCH 30 Pe 27-31 DIFF COUNT Basofil 1 * 0-1 Fosinoft 3 * 0-7 Neutrofil 82 . % 40-47 Limfosit 2 % 19-48 Monosit 8 % 3-8 Gol. Darah ABO ° Kimia Klinik ‘Glukosa Puasa 175 + mg/d Glukosa 2 jam pp 242 + mg/at. <180 Triglserida 134 mesa. <200 Kolesterol HOL 49 mg/d. >35 Kolesterol LDL 120 me/d. <150 Kolesterol Total 196 mg/dl <200 Bilirubin Total 0.63 mg/dl <1.00 Bilirubin Direct 0.27 + mesa <0.25 irubin indirect 036 mg/dl. <08s ALTL/SGPT 2B uf 0-41 ASTUSGOT 29 ut 0-32 Alkali Fosfatase 79.0 un 40.0 -130.0 Gamma-GT 57.0 . ut 11.0-50.0 Cholinesterase 11070 ul 5320-12520 Kreatinin 09 mg/dl. 07-12 Asam Urat a1 + mesa 34-70 BUN 15.00 mg/dl 6.00 - 20.00 Protein Total 6.23 é w/a 6.40 -8.30 Rumah Sakit Pertamina Balikpapan J Jend, Surman No. alikpapan Kalimantan Timur 76:11 1: (osea) 734030 Ext :772917733 ‘email :laboratorum@rspbid Web : wwwsspb idyA PERTAMEDIKA FRAMINA BINA HED Nama Tanggal lahir Jenis Kelamin Dokter Pengirim Alamat LABORATORIUM KLINIK 2 IHC RUMAH SAKIT PERTAMINA BALIKPAPAN Carporaion : Robert William Lobo, Mr NomorM.R : R10040923 23-05-1965 Order No. 111160106 Laki-laki Tangaal/ Waktu : 16-11-2021 9:47:48 AM Ri : 2: TRISUJI WATI, OR. tuangan MCU RSPB : PT. APEXINDO BALIKPAPAN Telp. 410258 EXT.202/0827042274 Terese: 651-08 bona Fae 209 Nama Tes Hasil Flag Unit Normal Keterangan Kimia Klinik — 7 aes ET e Foes Fy ESAT — : ine nse : ee Amoeba - Negatif Urinalisa i a ary kesay ener vont mt, Mog teen ae | Epitel os ‘APB <5.0 Rumah Sakit Pertamina Balikpapan JI. Jend, Suciman No.1 Babkpapan Kalimantan Timur 76111 1: (054a) 734020 6: 77291773 emai: laboratoriam@spbid web : wowesspb idwe a LABORATORIUM KLINIK RUMAH SAKIT PERTAMINA BALIKPAPAN 2 \HC Indonesia PERTAMEDIKA Corporation: FexiAMINA BR HED RA Nama : Robert William Lobo, Mr NomorM.R — : 810040923 ‘Tanggal lahir 2 23-05-1965 Order No. 2111160106 Jenis Kelamin = Laki-laki eee era aa TAB AM Dokter Pengirim — : TRISUII WATI, DR. Alamat : PT. APEXINDO BALIKPAPAN Telp. 2410258 EXT.202/0827042274 Tanggal Cetak: 16-11-2021. 3:15:00PM Page 3 of 3 Nama Tes Hasil Flag Unit Normal Keterangan Urinalisa Bae Bakten a * 19K Uvula @ ® Faringal wall Vy Nasal turbine Nose septum posterior part Orificium tuba custachius Torus Tubarius Fasse Rosenmuller ‘Adenoid Tonsil palatina ob Epiglotis ~ a Plika ariepiglotika \ Vocal fald false Vocal fald Aritenoid Subglotik Piriformis fassa Conclusion : “Ther Rumah Sakit Pertamina Balikpapan J. Jend. Sugirman No, 1 Balikpapan, Kalimantan Timur 76111 T : (0542) 734020, 734021 F : (0542) 736134 E-mail: rspbarspbid Web: www.rspbidPERTAMEDIKA PERTAMINA BINA MEDIKA RS PERTAMINA BALIKPAPAN IHC Indonesia Healthcare Corporation SP ‘AUDIOMETRE ‘re MCAT CHECK-UP 70 RALIRPAPAT TS FEET AMINA BALIRPAPAN KALIMANTAN TINUE Far a8/a09 Fax os734008 SG PATIENT DATA Teak Ramee aw Dae Tis Name(s KORTE WILT TOR Gear Se Dae (VMS TTS ‘Aires: MEDIRA PLAZA. Tie Te te Titre Nadler ADB Tone Audiogram RIGHT - FFL Ast 3s os nw a as As pall Cul. Jl Jend. Sudirman No. 1 Balikpapan, Kalimantan Timur 76111 T : (0542) 734020, 734021 F : (0542) 736134 rspberspb.id Web: www.rspb.idLABORATORIUM KLINIK 2 IHC RUMAH SAKIT PERTAMINA BALIKPAPAN, Indonesia shone PERTAMEDIKA FmLAMNA BNA EDN Nama Robert William Lobo, Mr NomorM.R = R10040923 Tanggal iahir 23-05-1965, Onder NG: $4ate0i06 TensKelanin tak Feat 26-204 ona Dokter Pengirim —: TRI SUJI WATI, DR. Alamat PT. APEXINDO BALIKPAPAN Telp. + 410258 EXT.202/0827042274 ‘Tanggal Cetak: 16-11-2021 14: Nama Tes Hasil Flag Unit Normal Keterangan Hemoglobin 15.4 e/a 140-180 Hematokrit 439 % 420-52.0 Eritrosit sa7 10%6/uL 4.70-6.10 Lekosit 787 1093/uL 4.80 - 10.80 Trombosit 24 1093/ub 150-450 Mcv 85 ff 81-99 MCHC 35 w/a 33-37 McH 30 Pe 27-3 DIFF COUNT Basofil % o-a Eosinofl % 0-7 Neutrofil 62 ' % 40-47 Limfosit 2 % 19-48 Monosit 8 % 3-9 Gol. Darah ABO ° ‘Glukosa Puasa 175 + mg/dl 70-110 Glukosa 2 jam pp 242 + masa <180 Triglserida 34 mg/d. < 200 Kolesterol HOL 49 me/at. >35 Kolesterol LDL 120 mg/dl < 150 Kolesterol Total 196 mg/dl <200 Bitirubin Total 063 mp/at. <1.00 Bilirubin Direct, 027 + mast <0.25 Bilirubin Indirect, 0.36 me/at. <0.85 ALTSGPT. B uA. o-at ASTUSGOT 29 ul 0-32 Alkali Fosfatase 79.0 un. 40.0-130.0 Gamma-GT 57.0 + un. 11.0-50.0 Cholinesterase 11070 up 5320-12920 Kreatinin 09 me/d. 07-12 Asam Urat a1 + mg/dl 34-70 BUN 15.00 ma/dt. 16.00 - 20.00 Protein Total 6.23 * w/a 6.40-8.30 Rumah Sakit Pertamina Balikpapan J. Jend, Surman No. + Balkpapan Kalvantan Timur 61 T:(os¢a)734020 Bet: 77291773 ‘email slaboratorum@rspbid Web: wre sspbidLABORATORIUM KLINIK a2 HC RUMAH SAKIT PERTAMINA BALIKPAPAN, Indonesia PERTAMEDIKA, corporation Fauna Nama Robert William Lobo, Mr Nomor M.R :R10040923 ‘Tanggal lahir 23-05-1965 Order No. 2111160106 Tangeal/Waktu : 16-11-2021 09:47:48 Jenis Kelamin ——: Lak-laki eee tecinee Dokter Pengirim —: TRI SUJI WATI, DR. Alamat PT. APEXINDO BALIKPAPAN, Telp. +: 410258 EXT.202/0827042274 ‘Tanggal Cetak: 16-11-2021 14:52:29 Page 2 of 3 Nama Tes Hasil Flag Unit Normal Keterangan ‘Albumin Globulin Alkhohol Darah 14 mg/dL <100 Ureum HBs ag Elia ‘Non Reaktif <1 ‘Anti HBs 10.4 miu/mt FAESES RUTIN > Warna 2 Kuning Konsistensi : lembek Lendir : Negatif Lekosit : Negatif Eritrosit : Negatif Amoeba - Negatif Telur Ascaris : Negatif Telur Ankylos Negatif URIN LENGKAP, - warna Kuning. Kuning Kekeruhan Jerrih Jernih BeratJenis 1.015 1.003-1.030 pH 50 48-78 Lekosit Urin Negatif Jat Negatit Nitrit Negatif Negatit ‘Albumin Urin neg. Negatit Glukosa / Reduksi Urin norm g/t Normal Keton /Aceton Urin Negatif mg/dl Negatit Urobilinogen orm me/dt Normat Bilirubin Negatif mg/dl Negatit Darah ( Hb/eri) Negatif Jat Negatit Epitel os Nee <5.0 Silinder Patologis 00 Pk <10 Rumah Sakit Pertamina Balikpapan_ J Jend, Sudrman No. xBallkpapan Kalimantan Timur 76101 7: (0542) 734020 Ext: 7729173, ‘emai: laboratoriam@rspbid Web: worw.rspbidSy , a LABORATORIUM KLINIK a IHC RUMAH SAKIT PERTAMINA BALIKPAPAN indonesia PERTAMEDIKA Sipe Nama : NomorM.R — : R10040923 Tanggallahir 23-05-1965 Order No. 2111160106 Jenis Kelamin ——: Lakiaki peel Wale Dokter Pengirim — :TRISUJIWATI, DR, Alamat : PT. APEXINDO BALIKPAPAN Telp. + 410258 EXT,202/0827042274 Tanggal Cetak: 16-11-2021 14:52:29 Page 3 of 3 Nena Tes Hasil Flag Unit Normal Keterangan Bakter it Kristal Negatt 1K Negatt Jamue Negatif 10K Negatt Lain lain Negatf 10K Negatt Lekost sedimen 02 108 00-50 EritostSedimen os 168 00-30 NARKOBA URIN Uji Narkoba Amphetamine Non Reaktt Non Reakit UjiNarkoba Methamphetamin Non Reaktf Non Reaktif Uj Narkoba Canabinoi Non Reaktt Non Reaktf Ui Narkoba Coceain Non Reaktt Non Reaktf Uji Narkoba Opiat Non Reaktt Non Reaktf Ui Narkoba Benzodiazepine Non Reaktif Non Reaktit Uj Narkoba Peneyclidin Non Reaktf Non Reaktif Uj Narkoba Methadon Non Reaktt Non Reaktf Dokter Penanggung Jawab : dr. Suryani Trismiasin. SpPK Rurmah Sakit Pertamina Balikpapan end Sudeman No.1 alkpapen Kalartan Tut 76 Tosa) 74030 877291723 ema labortorum@rapbid Web wensR AMINA BALIKPAPAN Indonesia Healthcare eeamauenwa = PIMC E Corporation ROBERT WILLIAM LOBO, Mr./ PT. COSL Reg. : RII21147167 EXAMINATION BY OPTHALMOLOGIST ANAMNESA. 1. Current eye problem: — Eye disorder history: — 3. Medical history pm 6 RTO DISTANT VISUAL ACUITY Uncorrected Correction Corrected Right GAs S ~1.25 br90sx 105 bf Left bias S~0-80 Of l NEAR VISUAL ACUITY (Addisi) : € # 2.40 Sy ISHIHARA TEST : Normal KONFRONTASI TEST TONOMETRY -Right; [1 -Left : 14. OCULAR POSITION : = Right( ortho, }}xovEso, Phoria/Trophy <> - Left (orFo,) :xo/Eso, Phoria/Trophy OCULAR MOVEMENT - Right al) Delayed - Left (Normal) Delayed BINOCULAR VISION Diplopia + /- ina Balikpapan J. Jend. Sudirman No. 1 Balikpapan, Kalimantan Timur 76111 Ts (0542) 734020, 734021 F : (0542) 736134 E-mail: rspb@rspb.id Web: www.rspb.idSia eats & IHC RS PERTAMINA BALIKPAPAN Indonesia Healthcare Corporation SLITLAMP BIOMIKROSKOPI Right Left Palpebra fl Conjungtiva Comea Anterior eye chamber dhe Iris dh Pupil Lens Vitreous FUNDUSKOPI Right Fath Pai t dhe Gtfary not Left Conelution Chow one Ko? Flow our Kort turd Balikpapan, November 16" 2021 Opthalmologist, RS. PERTANINA i Rumah Sakit Pertamina Balikpapan J, Jend, Sudirman No. 1 Balikpapan, Kalimantan Timur 7610 (0842) 734020, 734021 F : (0542) 736154 E-mail: rspb@rspb.id Web: www.rspb.id1AV/ERMIRSPB Rev 01 J Jenderal Sudiman No.1 NOMOR RADIOLOGI Telp, (0542) 734020, 734021, 734024 Fax. 736134 alkpapan - Kalimantan Timur 76111 Website: ww spb id ReMnatsenctes E-mail: cotomerareQopb i, setas@rapbid HASIL PEMERIKSAAN RADIOLOGI A RUMAH SAKIT PERTAMINA BALIKPAPAN Balikpapan, 16-Nov-21 No, RM, R100409 2.3 No. Registrasi Nama Mr. Robert Willam Lobo | ip To) Pemerksaan 16-Nov-21 Tanggal Lanir 29/05/1965 Penanggung PT..COSL INDO. Unit Pengirim MCU Dokter yang merawat Dr. Ti Suji Wat Thorax X-Ray . There is no sign of pleural thickening . Pulmonary structure is normal and shows normal vascular markings There are no intrapulmonary nodules The heart is normai size. Conclusion : The Heart and lung appear normal. USG Abdom Liver A slight diffuse increase in fine echoes in the hepatic parenchyma with normal visualization of diafragm and intrahepatic vessel border. {t presents a normal internal structure with no focal abnormalities, The pancreas is normal in size, position, and internal structure. Gallbladder: Apperance is normal, presenting smooth borders and homogenous contents, Kidneys Both kidneys appear normal in size and position, There is no evidence of a mass The renal pelvis is normal and free of stones, there is no obstruction of the urinary drainage. Spleen Normal size with the smooth border and normal attenuation values. It presents a normal internal structure with No focal abnormalities. ‘The urinary bladder has smooth outer countours and normal wall thickness. Conclusion : - Suspect Fatty Liver. ~ Gallbladder, Pancreas, Kidneys, Spleen and Urinary Bladder are within normal limits Salam sejawat, i | Dr. Debie EE. Poluan, Sp. Rad.RUMAH SAKIT PERTAMINA BALIKPAPAN 029/F RMIRSPB Rev 01 J denderal Sudirmen No.1 a ‘Teip, (0542) 734020, 724021, 734024 Fax, 736134 Batkoapan Kalman Timur 76111 RERTAMEDIKA Webste : vray rep Email: cutmereme@ap0 4, selretars dap LEMBAR KONSULTASI RAWAT JALAN an 0 Sut Wah’ Dokter yang meminta Di tujukan ke dokter on Tanggal: (2 vv 20 4% Umur th’bin denis Kelamin P- DIAGNOSAKERJA ; @™ petorn, Patty see . Ke slah we ky Iktisar Klinik: oy pst May ih Mev HOM 4 bus! tab. 6OP pe Aim ut Bl yet Na bet Grea 9%} rer sz wo vee 490 tastainalte? Sein dy He) (evabphonima 3s 4 = a Konsul Yang di minta : fn libin Yialealiive. (f vakalalen, #4 bond ae May Are JAWABAN Penemuan : bis Ul hb Al Diagnosaa PERTAMEDIKA PERNA BINA MEDIA Nama ‘Tanggal lahir Jenis Kelamin Dokter Pengirim Alamat LABORATORIUM KLINIK RUMAH SAKIT PERTAMINA BALIKPAPAN :Robert William Lobo Tn :23-05-1965 = Laki-laki : COSL INDO PANIN TOWER Nomor M.R. 19091334 Order No. :2111170188 Tangeal/Waktu : 17-11-2021 11:42:13 AN Ruangan SINTERNIS RSPB Nama Tes Hasil Flag Unit Normal Keterangan fn i a “I. Jend, Sudrman No. Balkpapan Kalimantan Timur 761 T:(o54a) 734020 Ext:7729273, ‘emall:laboratorium@rspbid Web: wow.sspbidRUMAH SAKIT PERTAMINA BALIKPAPAN é 4 Sengeral Suairman No.1 dla eB 0542) 734020, 704021, ro4N24 Fax 796194 Balspapan - Kalimantan Tamu 76111 PERTAMEDIKA Website: wonw.re0b id mail: customercare@rspb id, sekretaris@rspb id (O20/FRWRSPB Rev 01 LEMBAR KONSULTASI RAWAT JALAN Dokter yang meminta. =. Pag’ AA Di tujukan ke dokter @. Spur" Tanggal: HoweY o2q - ef wr Reber williar lobe M:| Umur: thi bin Jenis Kelamin :([)/ P DIAGNOSA KERJA su ae * wT bnlache | Iktisar Klinik oS gos) mou tL Nw MM ca rece | eid > SR, LAM, LAY, LY sing TOT 2 banGenita Shusg fest MD. Migirtt ky Henrgy vuropralol so oy Mm > O74 Konsul Yang di minta Molar erawntn & pertain a Ost 1M Ba dea avi Lg (orn RSG ) JAWABAN ht fr Pe J Re 18 be = oh hh a 6h te bok. Saran G TA Ti) ~ sie wood, | (6 Ke ph dae ny pe (2 Som Balikpapan, Cc Ft Sry ea PenemuanRUMAH SAKIT PERTAMINA BALIKPAPAN gy Jl. Jend, Sudirman No. 01 PERTAMEDICA “retp (0542) 734020 Fax. 736138 RUAINABANDIA Email : customercare@rspb.id tata 4 Balikpapan ~ Kalimantan Timur 76111 a) TREADMILL EXERCISE TEST REPORT (PROTOKOL BRUCE) Full Name : ROBERT WILLIAM LOBO, Mr. No. Register :RU21 Date of birth May, 23" 1965 ‘Company : PT. COSL Sex Male Date November, 162021 Weight 84 kg Height 170 cm Blood Preassure mmHg Exercise time Minutes ? Maximum heart rate YF minute (....%6 fom maximum hear ate) Maximum blood pressure mmHg f Reason for termination fy va’ Tate y “a Dyspnoe a Angina a Diny 2 Target heart rate attained > Sepment ST~T change a Upsloping ST depression > 1 mm ‘No change l > Aerobic capacity — vets “. Down Te vee > Level physical fitness . a Very poor a Poor ao Average Good a Very good vVvYY CONCLUSION i _oaive igen respons sgative ischemic response Borderline stress test Indeterminate (Target heart rate not attained) RECOMMENDATIO! - Camy K Crd Shy. OT May Retin hg tien [7 ae Sng Tobi oavid Al RS. FenIAlEe samme rexcnanen eames {+ HERNURSPS Rev 01 ELEKTROKARDIOGRAM