Sample Form - New Pre-Employment - MEDEX 001

MEDEX 001 - HEALTH SCREENING AND EXAMINATION RECORD
PERSONAL PARTICULARS (To be completed by employee / candidate)

Name: (as in NRIC/ Passport)
Address: Phone:
Mobile:
Sex: M / F Age: Marital Status: M / S / D / W
Date of last medical Name of AME
Current Job Title: Job location:
HEALTH ASSESSMENT TYPE

Pre-employment: Routine: Return to work:
Pre-placement: International posting / Others Job title:
Food Handlers / RPE Users / Confined Space / Professional Drivers
Job specific:
Electrician / Healthcare / Crane & Forklift Operators
SOCIAL AND OCCUPATIONAL HISTORY Y N REMARKS

1 Do you smoke? If yes, how many sticks per day?
2 If you are an ex-smoker, when did you stop?
3 Do you take alcohol regularly? If yes, amount per week?
Have you been exposed to health hazards such as noise, dust,
4
radiation, chemicals, heavy metals, etc.?
Have you used protective clothing, safety glasses, respirators,
5
hearing protection?
Have you suffered work related illness before – asthma, skin
6 condition, hearing loss, backache, blood disease, etc? If yes
please give details
Have you suffered work related injury before? If yes, please give
7
details
8 Have you had audiometry screening previously?
Have you been informed of abnormal audiometry results? If yes,
9
please give test date place done.
10 Have you had lung function test done previously?
If yes and results were abnormal, please give test date and place
11
done.
Have you had abnormal chest X-Ray before? If yes, please give
12
test date and place.
Have you been rejected from employment because of medical
13
reason previously?
Have you received compensation from work injury/ illness
14
before? Or is there such compensation pending?
MEDICAL HISTORY
Do you have or have been diagnosed as suffering from any of the following?
(Please tick yes or no and elaborate if appropriate) Y N Remarks
1 Chest pain / heart pain
2 High blood pressure / Stroke
3 Asthma / Epilepsy / Diabetes
4 Peptic ulcer disease
5 Kidney disease
6 Psychiatric disorders
7 Tuberculosis / Hepatitis A
8 Cancer
9 Do any of your family members (parents/ siblings) suffer from any of the above? If yes, please specify.
Do you currently have any of the following? Y N Remarks

1 Backache / joint or muscular pain
2 Hernia / rupture
3 Visual impairment
4 Perforated eardrum / discharge from the ears
5 Recurrent indigestion
6 Jaundice / Hepatitis / gall bladder disease
7 Change in bowel habit / diarrhoea
8 Blood in stools / piles / haemorrhoid
9 Shortness of breath / coughing out blood
10 Recurrent bronchitis / pneumonias
11 Blood in urine, renal or bladder stone / kidney problems
12 Headaches / migraine / dizziness
13 Cancers / breast lump
14 Pregnant
15 Visual or hearing problems
16 Any other illnesses
AME Comments
I hereby certify the above information is correct. I also understand that voluntary non-disclosure of any of information
required above is an offence and disciplinary action may be taken against me. I further agree to give consent to the
examining Approved Medical Examiner (AME) to disclose the results of this medical questionnaire and examination to
authorised PETRONAS Health Advisers, for the purpose of verification of my fitness to work status.
Name: ………………………………………………………………….. Signature: ……………………………………… Date: ……………………………

Employee / candidate identified using recommended identification document Y N
MEDICAL EXAMINATION AND LABORATORY TESTS (to be completed by attending AME)

Wt (Kg) Ht (Meters) BMI BP(mmHg) Pulse(per min) Blood Group
Distance Vision Near Vision Colour Vision

Uncorrected L R Both L R Both
Corrected L R Both L R Both
1 Eyes Y N 8 Skin Y N
2 Ear, Nose & Throat Y N 9 Genitourinary Y N
3 Oral / Teeth Y N 10 Musculoskeletal Y N
4 Lungs / Chest Y N 11 Breast Y N
5 Cardiovascular Y N 12 Neurological Y N
6 Abdomen Y N 13 Rectal Examination Y N
7 Hernia orifices Y N 14 Varicose veins Y N
CLINICAL AND LABORATORY TSET RESULTS (if indicated. Please mark NA if not done)
1 Audiometry 8 Serum Electrolytes
2 Chest X-Ray 9 Serum Lipids
3 Lung Function Test 10 Urea & Creatinine
4 ECG 11 Liver Function Test
5 Full Blood Count 12 Urine Drug Tests
6 Urinalysis 13 Stool C&S
7 Fasting Blood Glucose 14 Other Tests (specify below)
HEALTH ASSESSMENT RESULT
Fit for work
Unfit for work
Fit for work with restriction
AME Remarks:
AME’s Signature: ………………………………………………….. Date: …………………………………. Affix

AME Stamp
Name: ……………………………………………………………………………….…………………
Clinic Name/ Address: …………………………………………………………………………………….

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Sample Form - New Pre-Employment - MEDEX 001

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MEDEX 001 - HEALTH SCREENING AND EXAMINATION RECORD

PERSONAL PARTICULARS (To be completed by employee / candidate)

HEALTH ASSESSMENT TYPE

SOCIAL AND OCCUPATIONAL HISTORY Y N REMARKS

Do you currently have any of the following? Y N Remarks

Name: ………………………………………………………………….. Signature: ……………………………………… Date: ……………………………

MEDICAL EXAMINATION AND LABORATORY TESTS (to be completed by attending AME)

Distance Vision Near Vision Colour Vision

HEALTH ASSESSMENT RESULT

Fit for work

Unfit for work

Fit for work with restriction

AME’s Signature: ………………………………………………….. Date: …………………………………. Affix

Clinic Name/ Address: …………………………………………………………………………………….

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