ATTACHMENT C

YNSAB
Date: ____________

Time Arrival: ______

Time Departure: ___

Name of Employee: _______________________ Nationality: ____________ Age: _________

Company: ____________________________ Position: _______________________________

MEDICAL CONSULTATION REPORT

Temperature: ______________ BP: ______________ Pulse: _____________ RR: ___________

Complaints: ____________________________________________________________________

______________________________________________________________________________

Physical Examination: ___________________________________________________________

______________________________________________________________________________

HEAD: _______________________________________________________________________

ENT: _________________________________________________________________________

CHEST: ______________________________________________________________________

ABDOMEN: __________________________________________________________________

UPPER EXTREMITIES: ________________________________________________________

LOWER EXTREMITIES: _______________________________________________________

DIAGNOSIS: _________________________________________________________________

TREATMENT: _______________________________________________________________

_____________________________________________________________________________

DISPOSITION: _______________________________________________________________

REFERRAL TO: ______________________________________________________________

____________________

Medical Doctor

13c-Medical-Consultation.DOC