ToKLINIK

Management
System
ISO 9001:2015
PUSAT PEMERIKSAAN KESEHATAN TENAGA KERJA
tll.UEITILAB
Komplek Taman Niaga Sukajadi Btok I No. 3A-6 ll. Ahmad yani - Batam 29433
ID 9105042627 Telp: (0778) 7372022,7372023,081t770 1188,0811 770Lr99. Fax: (0778) 737ZOZ4
E-mail:

Preemployment Physical Examination

CONFIDENTIAL
No. Medical Record tilililill1iltililfi ]ilililililil|ilil|illil fl fll

0B4s0l096lLxluMl22
PERSONAL DATA
Name : NASIBTANATA SILABAN
Birthday/Gender/Emp. ID : 27 December 1991 I Male / 1211012712910003
Father's Name : HAPNAR SILABAN
Address : PERUM LEGENDA MALAKA BLOK C9 NO 12 BALOI PERMAI, BATAM
. Occupation
Name of Employer Agency : UMUM / Recruitment
/ Recruitment Agency : , BATAM
Address of Employer

MEDICAL HISTORY
Yes No Yes No YeS No

1. Hypertension t] tr 4. Allergic Rhinitis tr tr 7. Surgery TE

n tr
2. Bronchial Asthma tr m 5. Peptic Ulcer tr tr B. Echolalia

3. Bloody Cough il tr 6. Epilepsy n tr 9. Others l L!

CLINICAL EXAMINATION Yes/Abnormal No/Normal
3. Cardiovascular System
Weight : 62 Kg :
BMI
Height
23.05
164 Cm
a. Blood Pressure
Systolic / Diastolic :128175 mmHg
tr E
Yes/Abnormal No/Normal
: 83/min

Ttr
1. Vision Pulse

a. Distant Vision b. Heart Disease T

T
I
( Should be at least 6/12 inn both eyes with or

trtr without glasses ) c. Varicose Veins X

.

b. Near Vision 4. Respiratory System u I

u
( Should be at least 12
c. Colour Vision
n both
nth
trtr
.Ttr
eyes with or wlthout glasses ) 5. Skin-Chronic Disease
6. Abdomen tr
u
J
X
d. Any Organic Eye
2. Hearing

at2m)
( Unable to hear ordinary conversationat2m)
Disease

utr 7. Locomotor/Neurological
8. Endocrine disorders
9. Mental State
T
u
X
X
X

LABORATORY TEST OTHER TEST

( Report Enclosed )
Yes/ Abnormal No/Normal
( Repoft Enclosed ) Yes/ Abnormal No/Normal

tr E tr
1.
2.
3.
Blood Count
Urine Feme
Other.Laboratory Test
rtr
E
tr
tr
1. Audiometry
2. Spirometry

3. ECG ( if indicated )
tr
tr
tr
tr
Remdrks: Retained Dental Root K08.3 1, E.N.T: Right Ear Cerumen H6t.2t, Blood Count: Monocytosis D72.B2t
4. Chest X-Ray u
11.8o/o
E
CERTIFICATION
I certify that I have examined the abovenamed person. In my opinion, this person is FIT for duties mentioned above.
ADVICE: .
Authentic Signature
Teeth & Ear Hygiene

Date of Exam : 3 September 2022

lil 11ilil1ffiilflfiilflIillililfiltilil1lliltll
DR. RINDI NURSA'ADAH SAGALA
 ffioKLINIK
Management
System
ISO 9001:2015
PUSAT PEMERIKSAAN KESEHATAN TENAGA KERJA
iltIrEIrIUrB
Komplek Taman Niaga Sukajadi Blok I No. 3A-6 ll. Ahmad Yani - Batam 29433
to 9105042627 Telp: (0778) 7372022,7372023,0811 770 1188, 0811 77O 1199. Fax: (0778) 7372024
E-mail: customercare@medilab-clinic.com, Website: www.medilab-clinic.com

HEALTH SCREENING REPOR1

Preemployment Physical Examination
CONFIDENTIAL 108644
No. Medical Record iltlililffi ililtfi ililililfiililffi iltfilltilr |lilI
0B4s0l096lrx/uMl22
PERSONAL DATA
Name NASIB TANATA SILABAN
Birthday/Gender/Emp. ID 27 December 1991 / Male I L2L70L27129L0043
Fatheas Name HAPNAR SILABAN
. Address PERUM LEGENDA MALAKA BLOK C9 NO 12 BALOI PERMAI, BATAM
Occupation
Name of Employer / Recruitment Agency : UMUM
Address of Employer / Recruitment Agency : , BATAM
LABORATORY REPORT
BLOOD COUNT
Test Name Result Unit Reference Range
HGB 16.1 grldl M: 13.2- 17.3 F'.1L.7- 15.5
WBC 9.6 103/ mm3 M: 3.8 - 10.6 F: 3.6 - 11.0
RBC 5.15 196/ 6m: M: 4.4 - 5,9 F: 3.8 - 5.2
ESR 2 mmlhr M: 0 -10 F: 0 -20
HCT 47.0 0/o M: 40 - 52 F:35 - 47
PLT 2L7 lQ:/rn6: 150 - 440
Differential Count
. LYM 33.0 o/o 25 40
- MON * 11.8 o/o 2- B
- GRA 55.2 o/o +3 76
URINE FEME
Macroscopy .. Result
-pH 6
- Specific Gravity 1.010
- Glucossa Negative
- Protein Negative
- Ketones Negative
- Bilirubin Negative
- Urobilinogen Normal
- Nitrit Negative
- Blood Negative
- Leucocytes Negative

X.RAY REPORT
Chest PA:
Show no Abnormalitis.
There is no evidence of pulmonary tuberculosis or other pulmonary,pleural or mediastinal lesionS.
The size,shape and position of the heart are within limits of normal variations.
Bony structures ofthe thorax show no abnormalities.

Date of Exam : 3 September 2022

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