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  • TKO Medical Check-Up

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    Andri San
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    This document outlines a medical form for visitors to a site that collects personal details and conducts a medical assessment. The form collects information like name, company, nationality, date of birth, contact details, and blood type. It then has a medical assessment section that asks questions about any known allergies, surgeries, illnesses, medical history, medications, and other relevant medical information. The assessment also includes a physical examination of general condition and vital signs. The form is to be signed by medical staff.

    Original Description:

    Medical Form Visitor

    Original Title

    Medical Form Visitor

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    This document outlines a medical form for visitors to a site that collects personal details and conducts a medical assessment. The form collects information like name, company, nationality, date of birth, contact details, and blood type. It then has a medical assessment section that asks questions about any known allergies, surgeries, illnesses, medical history, medications, and other relevant medical information. The assessment also includes a physical examination of general condition and vital signs. The form is to be signed by medical staff.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    11 views1 page

    TKO Medical Check-Up

    Uploaded by

    Andri San
    This document outlines a medical form for visitors to a site that collects personal details and conducts a medical assessment. The form collects information like name, company, nationality, date of birth, contact details, and blood type. It then has a medical assessment section that asks questions about any known allergies, surgeries, illnesses, medical history, medications, and other relevant medical information. The assessment also includes a physical examination of general condition and vital signs. The form is to be signed by medical staff.

    Copyright:

    © All Rights Reserved
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    of 1

    TATA KERJA ORGANISASI

    DOC OWNER :HSSE-HEA DOC NUMBER :MHK-COMP-TKO-HSE-MED-0005


    REVISION NO :1
    TITLE :HSE 06-610 MEDICAL CHECK- EFFECTIVE DATE :02-09-2022
    UP AND FITNESS TO WORK
    EXPIRED DATE :02-09-2025
    This document is the property of PT PERTAMINA HULU MAHAKAM (PHM). It must not be stored, reproduced or disclosed to others without written authorisation from PT PHM.

    PAGE :101 of 108

    Medical Form for Visitor


    Site:

    Personal Details

    1. Name :
    2. Company/ Position :
    3. Nationality :
    J0292024 - Sulaiman RASYID | Uncontrolled Paper Copy | CMS | 06-12-2022 4:18 PM

    4. Date of Birth :
    5. Contact Address :
    6. Phone Number :
    7. Blood Type : A/B/AB/0* ; Rhesus : Positive/Negative*
    8. Emergency Contact Person
    a. Name :
    b. Phone Number :

    Medical Assessment

    No Health Assessments Remark (if Yes, please explain)

    1 Any known allergy, surgery or recent illness

    2 Any Medical History/Chronic Disease Control


    3 Current prescribed medication taken
    4 Any other relevant medical information

    Physical Examination:
    5 - General Condition:
    - Vital Sign (Blood Pressure, Heart Rate)

    Medical Staff Comment:

    Signed by Medical Staff:


    Date:
    Name:_______________

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