LEVEL 3 – STANDARD SD-NOC-HIH-018

Fitness To Work

Rev.: 04 Effective date: 05/2022 Page: 1 of 24

Attachment 2 - Health Status Questionnaire

Please answer the questions by ticking the correct box. If you are not sure, leave the question blank and
ask your health advisor what it means. Your health advisor may ask you additional questions during the
examination.

Last Name: PAINO First Name: IRWANTO

Weight (kg): 62 Height (cm): 158 CM

Occupation: WELDER Date: JULI, 10th 2023

QID or Passport No.: E0744874 Mobile No.: +62 813 6628 4351

No Yes
1. Are you currently being treated by a doctor for any illness or injury? √ 🞅
If yes please briefly describe

2. Are you receiving any medical treatment or taking any medication (either prescribed or √ 🞅
otherwise)?
If yes please list here

3. Have you ever had, or been told by a doctor that you had any of the following? No Yes

3.1 High blood pressure √ 🞅

3.2 Heart disease √ 🞅
3.3 Chest pain, angina √ 🞅
3.4 Any condition requiring heart surgery √ 🞅
3.5 Palpitations/irregular heartbeat √ 🞅
3.6 Abnormal shortness of breath √ 🞅
3.7 Head injury, spinal injury √ 🞅
3.8 Seizures, fits, convulsions, epilepsy √ 🞅
3.9 Blackouts, fainting √ 🞅
3.10 Stroke √ 🞅
3.11 Dizziness, vertigo, problems with balance √ 🞅
3.12 Double vision, difficulty seeing √ 🞅
3.13 Colour blindness √ 🞅
3.14 Kidney disease or kidney stones √ 🞅
3.15 Diabetes √ 🞅
3.16 Neck, back or limb disorders √ 🞅

This document is proprietary to North Oil Company and contains confidential information which may not be reproduced, stored, disclosed or transmitted to any
third party, without the prior written consent of North Oil Company.
The information contained in this document does not substitute for the laws and regulations applicable in Qatar.
Printed versions of this document are uncontrolled, check CMS for latest version.
 LEVEL 3 – STANDARD SD-NOC-HIH-018

Fitness To Work

Rev.: 04 Effective date: 05/2022 Page: 2 of 24

Health Status Questionnaire (verso) No Yes

3.17 Hearing loss or deafness or had an ear operation or use a hearing aid √ 🞅
3.18 Do you have difficulty hearing people on the telephone (including use of hearing aid if worn)? √ 🞅
3.19 Have you ever had, or been told by a doctor that you had a psychiatric illness, or nervous disorder? √ 🞅

3.20 Have you ever had any other serious injury, illness, operation, or been in hospital for any reason? √ 🞅
If yes, please list here

3.21 Have you ever had, or been told by a doctor that you had a sleep disorder, sleep apnoea, or narcolepsy? √ 🞅

3.22 Has anyone noticed that your breathing stops or is disrupted by episodes of choking during your sleep? √ 🞅

3.23 Were you diagnosed with COVID-19? √ 🞅

4. Do you consume alcohol? √ 🞅

4.1 If yes, how many units per week? …………………………

5. Do you use illicit drugs? √ 🞅

5.1 Have you ever been treated for alcohol or substance abuse? √ 🞅

6. Do you use any drugs or medications not prescribed for you by a doctor? √ 🞅
If yes, please list here

7. Do you smoke tobacco? √ 🞅

7.1 If yes list how much do you smoke per day ……….…………..
7.2 If you quit smoking indicate when ………………………………

8. [Drivers only] - Have you been in a vehicle crash since your last license examination? √ 🞅
If yes, please give details

Declaration: I, IRWANTO PAINO (Print Name) certify that to

the best of my knowledge the above information supplied by me is true and correct.

Signature: Date: September, 08th 2023

This document is proprietary to North Oil Company and contains confidential information which may not be reproduced, stored, disclosed or transmitted to any
third party, without the prior written consent of North Oil Company.
The information contained in this document does not substitute for the laws and regulations applicable in Qatar.
Printed versions of this document are uncontrolled, check CMS for latest version.
 LEVEL 3 – STANDARD SD-NOC-HIH-018

Fitness To Work

Rev.: 04 Effective date: 05/2022 Page: 3 of 24

Attachment 3 - Consent to Release Personal Health Information

I, IRWANTO PAINO Date of Birth June, 18th 1988 ,

(print name of person giving consent)

Employed by SUBSEA 7 , hereby authorize

(print name of Employment Company)

, to release
(print name of health information custodian)

 All of my health information that the medical provider has in his or her possession, including
information relating to any medical history, mental or physical condition and any treatment
received by me;

 Only the results and analysis of my fitness to work medical exams;

 Only the information related to ongoing medical and nursing care;

to the North Oil Company Medical Advisor and Nurse, for review, consultation and storage in my
personal medical file. This information will be treated by the North Oil Company on a strictly
confidential basis.
I understand the purpose for disclosing this personal health information to the NOC Medical Advisor.
This consent shall remain in force for 12 months following the date of my signature below. The copy
of this consent is as valid as the original.
I understand that I can refuse to sign this consent form or revoke it at any time except to the extent that action
has been taken in reliance on it.

Date: September, 08th 2023 Signature:

This document is proprietary to North Oil Company and contains confidential information which may not be reproduced, stored, disclosed or transmitted to any
third party, without the prior written consent of North Oil Company.
The information contained in this document does not substitute for the laws and regulations applicable in Qatar.
Printed versions of this document are uncontrolled, check CMS for latest version.