DOLE/BWC/HSD/OH-47-A

Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT
Region 7

ANNUAL MEDICAL REPORT FORM

For Period January 1, 2020 to December 31, 2020

1. Name of Establishment:
2. Address:
3. Name of Owner/Manager:
4. Nature of Business and Production/Service (Ex. Manufacturing Textile):
5. Total Number of Employees: Number of Shifts:
6. Number Distribution of Employees as to nature/workplace, sex and workshift:
Office Production/Shop

1st Shift 2nd Shift 3rd Shift

Male : __________ __________ __________ __________

Female: __________ __________ __________ __________
Total : __________ __________ __________ __________

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

a. Occupational health services is organized/provided by:
( ) the establishment/undertaking
( ) government authority/institution
( ) other bodies/groups/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/undertaking
( ) common to a number of establishments/undertakings ___________________________
______________________________________________________________________

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 : _________________________________________________________
Address : _________________________________________________________

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

workplace:
( ) once every month ( ) once every three (3) months
( ) once every two (2) months ( ) once every six (6) months
( ) other details ____________________________________________________________

8. Emergency Occupational Health Services:

a. The employer provides a treatment room/medical clinic in the workplace with medicines and
facilities:
( ) yes ( ) no
( ) others, please specify _____________________________________________________
_______________________________________________________________________

b. Schedule of attendance in the workplace:

Work shift

Occupational health physician : ________________ hrs./day _____________

Occupational health dentist : ________________ hrs./day _____________
Occupational health practitioner : ________________ hrs./day _____________
Occupational health nurse : ________________ hrs./day _____________

c. Schedule of attendance of full time first aider:

 ( ) 1st work shift
( ) 2nd work shift
( ) 3rd work shift

d. The following occupational health personnel of the establishment have undergone training in
occupational health and safety/first aid:
( ) occupational health physician
( ) occupational health dentist
( ) occupational health nurse
( ) first aider
( ) others, please specify _____________________________________________________
_______________________________________________________________________

9. Occupational Health Services:

a. The occupational health personnel of this establishment conducts regular appraisal of the
sanitation system in the workplace::
( ) yes ( ) no

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

Physical Exam X-Rays Urinalysis

1. Pre-placement ______________ _____________ ________________
2. Periodic ______________ _____________ ________________
3. Return-to-work ______________ _____________
________________
4. Transfer ______________ _____________ ________________
5. Special ______________ _____________ ________________
6 Separation ______________ _____________ ________________

Stool Exam Blood Test ECG Others

1. Pre-placement __________ __________ ________ __________
2. Periodic __________ __________ ________ __________
3. Return-to-work __________ __________ ________ __________
4. Transfer __________ __________ ________ __________
5. Special __________ __________ ________ __________
6. Separation __________ __________ ________ __________

10. Report of Diseases:

a. Number of consultations/treatments for the following diseases:
Male Female Total Number
of Cases
Skin:
( ) allergy _______ _______ ___________
( ) dermatoses _______ _______ ___________
( ) infection as folliculitis
abscess/paro nychia _______ _______ ___________
( ) Others _______ _______ ___________
Head:
( ) tension headache _______ _______ ___________
( ) Others _______ _______ ___________
Eyes:
( ) error of refraction _______ _______ ___________
( ) bacterial/viral
conjunctivities _______ _______ ___________
( ) cataract _______ _______ ___________
( ) Others _______ _______ ___________
Mouth & ENT:
( ) Gingivitis _______ _______ ___________
( ) Herpes labiales/nasalis _______ _______ ___________
( ) Otitis Media/Externa _______ _______ ___________
( ) Deafness _______ _______ ___________
( ) Menlere’s Syndrome/Vertigo _______ _______ ___________
( ) Rhinitis/Colds _______ _______ ___________
( ) Nasal Polyps _______ _______ ___________
( ) Sinusitis _______ _______ ___________
( ) Tonsillopharyngitis _______ _______ ___________
( ) Laryngitis _______ _______ ___________
( ) Others _______ _______ ___________
Respiratory:
( ) Bronchitis _______ _______ ___________
( ) Bronchial asthma _______ _______ ___________
( ) Pneumonia _______ _______ ___________
( ) Tuberculosis _______ _______ ___________
 ( ) Pneumoconiosis _______ _______ __________
( ) Others _______ _______ ___________
Heart and Blood Vessel:
( ) Hypertension _______ _______ ___________
( ) Hypotension _______ _______ ___________
( ) Angina Pectoria _______ _______ ___________
( ) Myocardial Infraction _______ _______ ___________
( ) Vascular disturbances in
extremeties due to
continuous vibration _______ _______ ___________
( ) Others _______ _______ ___________

Gastrointestinal:
( ) gastroenteritis/darrhea _______ _______ ___________
( ) amoebiasis _______ _______ ___________
( ) gastritis/hyperacidity _______ _______ ___________
( ) appendicitis _______ _______ ___________
( ) infectious hepatitis _______ _______ ___________
( ) liver cirrhosis _______ _______ ___________
( ) hepatic abscess _______ _______ ___________
( ) cancer (hepatic/gastric) _______ _______ ___________
( ) ulcer _______ _______ ___________
( ) Others _______ _______ ___________

Male Female Total Number

Of Cases
Genito Urinary:
( ) Urinary tract infection _______ _______ ___________
( ) Stones _______ _______ ___________
( ) Cancer _______ _______ ___________
( ) Others _______ _______ ___________

Reproductive:
( ) Dysmenorrhea _______ _______ ___________
( ) Infection (Cervicitis) _______ _______ ___________
(vaginitis) _______ _______ ___________
( ) Abortion (Spontaneous) _______ _______ ___________
(Threatened) _______ _______ ___________
( ) Hyperemesis Gravidarium _______ _______ ___________
( ) Uterine Tumors _______ _______ ___________
( ) Cervical Polyp/Cancer _______ _______ ___________
( ) Ovarian Cyst/Tumors _______ _______ ___________
( ) Sexually-Transmitted
diseases _______ _______ ___________
( ) Hernia (Inguinal) _______ _______ ___________
(Femoral) _______ _______ ___________
( ) Others _______ _______ ___________

Neuromuscular/Skeletal/Joints:
( ) Peripheral Neuritis _______ _______ ___________
( ) Torticollis _______ _______ ___________
( ) Arthritis _______ _______ ___________
( ) Others _______ _______ ___________

Lymphatics and Circulatory:

( ) Anemia _______ _______ ___________
( ) Leukemia _______ _______ ___________
( ) Cerebrovascular Accidents _______ _______ ___________
( ) Lymphadenitis _______ _______
___________
( ) Lymphoma _______ _______ ___________

Infectious Diseases:
( ) Influenza _______ _______ ___________
( ) Typhoid/paratyphoid fever _______ _______ ___________
( ) Cholera _______ _______ ___________
( ) Measles _______ _______ ___________
( ) tetanus _______ _______ ___________
( ) Malaria _______ _______ ___________
( ) Schistosomiasis _______ _______ ___________
( ) Herpes Zoster _______ _______ ___________
( ) Chicken Pox _______ _______ ___________
( ) German Measles _______ _______ ___________
 ( ) Rabies _______ _______ ___________
( ) Others _______ _______ ___________

Diseases due to Physical Environment:

a) Diseases due to Noise and vibration
( ) Deafness (noise induced) _______ _______ ___________
( ) White fingers disease _______ _______ ___________
( ) Musculo-skeletal
disturbances _______ _______ ___________
( ) Fatigue _______ _______ ___________

b) Diseases due to Temperature

And Humidity abnormalities:
Hot Temperature:
( ) heat strokes _______ _______ ___________
( ) heat cramps _______ _______ ___________
( ) dehydration _______ _______ ___________
( ) heat exhaustion _______ _______ ___________
( ) others _______ _______ ___________
Cold Temperature:
( ) Chilblain _______ _______ ___________
( ) frost bite _______ _______ ___________
( ) immersion foot _______ _______ ___________
( ) general hypothemia _______ _______ ___________
( ) others _______ _______ ___________

c) Diseases due to Pressure

Abnormalities:
( ) Decompression Sickness:
( ) air emboism _______ _______ ___________
( ) bends disease _______ _______ ___________
( ) barotrauma _______ _______ ___________
( ) hypoxia _______ _______ ___________
( ) altitude sickness _______ _______ ___________

Male Female Total Number

of Cases
d) Diseases due to radiation:
( ) cataracts _______ _______ ___________
( ) keratitis _______ _______ ___________
( ) burns _______ _______ ___________
( ) radiation-related cancers _______ _______ ___________
TOTAL NUMBER _______ _______ ___________

11. Report of Occupational Accidents/Injuries:

Nature Male Female Number of
Cases
Contussion, bruises, hematoma _______ _______ ___________
Abrasions _______ _______ ___________
Cuts, lacerations, punctures _______ _______ ___________
Concussion _______ _______ ___________
Avulsion _______ _______ ___________
Amputation, loss of body parts _______ _______ ___________
Crushing Injuries _______ _______ ___________
Spinal injuries _______ _______ ___________
Cranial Injuries _______ _______ ___________
Sprains _______ _______ ___________
Dislocation/Fractures _______ _______ ___________
Burns _______ _______ ___________

12. Immunization Program

(Indicate number immunized) Male Female Total

Tetanus Toxoid Injection _______ _______ ___________

Tetanus Antitoxin Injection _______ _______ ___________
Tetanus Globulin Injection _______ _______ ___________
Hepatitis B Vaccine _______ _______ ___________
Rabies Vaccine _______ _______ ___________
Others (Please specify) _______ _______ ___________

13. Keeping of Medical records of Workers (Please check)

( ) done ( ) not done
14. Health Education and Counselling by Health and Safety Personnel: (Please check one ormore)

( ) done individually 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 Seminar Use of Visual Counselling

Aid/Materials

Nutrition Program
Maternal and Child Care Program
Family Planning Program
Mental Health Activities
Personal Health Maintenance

Physical fitness Program: (Please check)

Sports Activities ( ) Yes ( ) No

Others (Please specify) ( ) Yes ( ) No

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

Substances and/or Number of workers

Sources exposed

a) Chemical Hazards:
( ) dust (Ex. Silica dust) ________________ ________________
( ) liquids (Ex. Mercury) ________________ ________________
( ) mist/fumes/vapors (Ex. Mist
from paint spraying) ________________ ________________
( ) gas (Ex. CO, H2S) ________________ ________________
( ) others (please specify)
(Ex. Solvents) ________________ ________________

b) Physical Hazards:
( ) noise ________________ ________________
( ) temperature/humidity ________________ ________________
( ) pressure ________________ ________________
( ) illumination ________________ ________________
( ) radiation/ultraviolet/
microwave ________________ ________________
( ) vibration ________________ ________________
( ) Others (Please specify) ________________ ________________

c) Biological Hazards:
( ) Viral ________________ ________________
( ) Bacterial ________________ ________________
( ) Fungal ________________ ________________
( ) Parasitic ________________ ________________
( ) Others ________________ ________________

d) Ergonomic Stress:
( ) Exhausting physical work ________________ ________________
( ) Prolonged standing ________________ ________________
( ) Excessive mental effort ________________ ________________
( ) Unfavorable work posture ________________ ________________
( ) Static/monotonous work ________________ ________________
( ) Others, specify ________________ ________________

Submitted by:

_______________________________ ___________________
Medical Personnel/Title Date

Noted by:
________________________________

Employer