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    FOMEMA Physical Examination Forms Including XRay

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    nicholas

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    © All Rights Reserved
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    FOMEMA Physical Examination Forms Including XRay

    Uploaded by

    nicholas
    5 views4 pages

    Original Title

    FOMEMA Physical Examination Forms including XRay

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    5 views4 pages

    FOMEMA Physical Examination Forms Including XRay

    Uploaded by

    nicholas

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    DATE CLINIC NAME

    PATIENT NAME DOCTOR NAME


    WORKER CODE

    MEDICAL CHECK,UP FOMEMA


    PART I MEDICAL HISTORY LMP

    Comments

    PART II SYSTEM EXAMINATION

    1. CARDIOVASCULAR SYSTEM
    2. RESPIRATORY SYSTEM
    3. GASTROINTESTINAL SYSTEM
    4, NERVOUS SYSTEM AND MENTAL STATUS
    5. GENITOURINARYSYSTEM

    PART III PHYSICAL EXAMINATION AND INVESTIGATION

    1. HEIGHT : CM 4. BLOOD PRESSURE


    2. wElcHT : -- KG SYstolic: mm Hg
    3. PULSE . PER MIN Diastolic. mm Hg
    --
    VISION TEST -
    DEFECTIVE NORMAL
    Unaided L -
    R
    Aided L
    R

    Hearing Ability L
    R

    PART IV LABORATORY RESULT AND X.RAY FINDINGS

    Comments

    LAB

    X-RAY :

    SIGNATURE WORKERS
    PART V CERTIFICATION BY DOCTOR
    YES NO
    1. HIV / AIDS
    2. TUBERCULOSIS
    3. MALARIA
    4. LEPROSY
    5. SEXUALLY TRANSMITTED DISEASES
    6. HEPATITIS
    7. CANCER
    8. EPILASY
    9. PSYCHIATRIC ILLNESSV
    10. She is pregrant
    11" His / Her urine contains opiates
    12. His / Her urine contains cannabis

    13. I THEREFORE CERTIRY THAT HE / SHE IS


    FOR EMPLOYMENT

    IF CONSIDERED NOT FIT FOR EMPLOYMENT PLEASE STATE THE REASON

    PART VI OUTCOME (To be completed by the Doctor)

    NO DATE
    1. Health Office is being notified

    2. I am referring the case to Government


    Hospitai. (e.9. mental illness, etc)

    I am referring the case to a prive


    Hospital.

    4. I am treating the patient.

    5.n The patient is still undergoing


    Treatment.

    Signature and Name of the Doctor


    FORE|cN WORKER CONSENT AUTHORTSATTON

    AND DECLARATION FORM

    This is to confirm thot l,


    fNome of Foreign Worker)

    Worker's code possport number


    (Worker's code/ /Possporf No.J

    hereby irrevocobly conseni ond outhorise Dr.


    fDocfor's Nome/

    of to:-
    fNome of clinic)

    i. corry oui o medicol exominotion on me including the testing of blood


    ond urine ond ihe toking of chest x-roy os required by the FOMEMA
    screening progromme, ond

    ii. disclose my heolth repori / records ond ony oiher heolth informotion to
    FOMEMA Sdn. Bhd., the Ministry of Heolih, the lmmigrotion Deportment,
    employer ond ony other relevont outhorities, os ond when it is required to
    do so.

    lolso hereby confirm the following:

    i" Ihove not token/ token * (if foken, pieose specify) ony medicotion / drugs
    within ihe lost two (2) weeks,

    (o) (b) (c)

    ii. My lost mensiruol period wos on _ I _ I (DD/MM/yy).

    Signoture or thumbprint of Foreign Worker Dote

    Witnessed by:

    Signoture of Exomining Doctor Nome of Exomining Doctor

    Clinic's Stomp
    FOMEMA X.RAY REPORT

    Name of Foreign Worker :

    Worker Code : Date of report:

    Abnormal Normal Details of abnormalitv

    1. Thoracic Cage

    2. Heart Shape and Size (CTR if applicable)

    3. Lung Fields

    4. Mediastinum and hila

    5. Pleura / Hemidiaphragms / costopherenic angles

    Yes No

    6. Focal lesion (e.9. PTB (old / new), maglinancy, etc.)

    7. Any other abnormalities

    IMPRESSION:

    Signature and Name of reporting GP Radiologist Clinc Stamp

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