MEDICAL STATUS REPORT FORM

PERSONAL INFORMATION
AFANDI CHORULLAH 6-21-1992
LAST NAME FIRSTNAME(S) COMPANY CREW ID DATE OF BIRTH (DD-MM-YYYY)
MEDICAL REPORT
3-14-2023 ANNA MEDIKA HOSP
DATE OF EVALUATION LOCATION / HOSPITAL

DIAGNOSIS
SURGICAL TREATMENT (HANDS)

EXAMINATION / SPECIAL INVESTIGATION FINDINGS (IF ANY)

BASE ON EXAM CT SCAN : Artritis reumatoid in hands, Theres something problem in hands, The main symptom of this disorder is swollen
joints that feel painful and stiff.

TREATMENT OR PROCEDURES CONDUCTED (IF ANY)

SURGICAL TREATMENT :
Hand surgery consultation is a safe procedure that patients must undergo to ensure the safety and success of hand surgery.

FURTHER FOLLOW UP FOR TREATMENT REQUIRED (YES/NO) (IF YES, IDENTIFY RECCOMENDED TREATMENT)
Yes
The patient will undergo a physical examination of the hands. During the consultation, the doctor will discuss treatment options and
recommendations according to the disease, severity, and health conditions and needs of the patient.

Has the patient reached Maximum Medical Improvement (MMI)? YES ☐ NO ☐ If yes, date of MMI: 3-21-2023
The definition of Maximum Medical Improvement is as follows: when it appears probable that further treatment will result in no betterment of the
seaman’s condition. Thus, where the seaman’s condition is incurable, or chronic, or that future treatment will merely relieve pain and suffering but
not otherwise improve the seaman’s physical condition, it is proper to declare that the point of maximum cure has been achieved.
FITNESS TO WORK / TRAVEL
Is the patient fit to work? YES ☐ NO ☐ Are there any restrictions? YES ☐ NO ☐
If there are any restrictions, please specify what and for what duration:
He may return to work in one weekwith only moderate activity.

Is the team member able to travel via commercial airline? YES ☐ NO ☐

PHYSICIAN DETAILS

NAME MEDICAL LICENSE NUMBER SPECIALTY

General Surgeon
Doctor Nurul Hidayat
DAY-MONTH-YEAR
SIGNED DATE SIGNED (DD-MM-YYYY)