Form Annual MCU
Form Annual MCU
01
Pekela
NO :
Nama : ………………………………………………………
Tempat & Tgl. lahir : ……………………………………………………… (L/P)
Status pernikahan : Kawin /blm.kawin / duda / janda
Jumlah anak : ………………. orang
Pendidikan terakhir : ………………………………………………………
Selama ini bekerja
di : ………………………………………………………
Alamat sekarang : ………………………………………………………
………………………………………………………
Tlp …………..
Akan memberikan jawaban atas pertanyaan dibawah ini dengan sebenarnya, karena saya
mengerti bahwa bila ternyata jawaban yang saya berikan tidak benar, dapat membebaskan
PT. Unilever Indonesia Tbk dari segala kewajiban terhadap diri saya.
Saya bersedia melakukan pemeriksaan sesuai dengan standard yang telah ditentukan.
Saya memberi kuasa kepada dokter yang telah atau akan memeriksa diri saya untuk memberi
keterangan seluas-luasnya tentang keadaan kesehatan saya.
Saya mengerti bahwa pemeriksaan kesehatan ini merupakan persyaratan dalam proses kerja
yang ditetapkan dan informasi dari pemeriksaan ini merupakan hak milik perusahaan.
( ............................ ) (…………………………………)
(Hasil anamnesa di bawah ini diisi oleh dokter pemeriksa / perawat yang berwenang)
Page 2 of 6 G.46.0.73.04.01
LAPORAN
PEMERIKSAAN KESEHATAN BERKALA
Hari.................Tgl........Bln.......Thn........
I. Identitas
Nama / NIP / Gol : .................................................................................
Tempat & Tgl.Lahir : ................................................................................
Job tittle : .................................................................................
Status keluarga : .................................................................................
Alamat : .................................................................................
.................................................................................
..............................................Telp : .........................
II. Anamnesis
Riwayat pekerjaan : .................................................................................
.................................................................................
Area kerja / Pabrik : .................................................................................
Mulai bekerja di area ini : .................................................................................
Keluhan sekarang :
- Pernafasan : .................................................................................
.................................................................................
- Kulit : .................................................................................
.................................................................................
- Pendengaran : .................................................................................
.................................................................................
- Muskuloskeletal : .................................................................................
.................................................................................
Riwayat penyakit : .................................................................................
..................................................................................
Operasi : .................................................................................
Rawat inap : .................................................................................
.................................................................................
Allergi : .................................................................................
.................................................................................
Kebiasaan merokok : .................................................................................
.................................................................................
Lain - lain : .................................................................................
.................................................................................
.................................................................................
Extremitas :
- Reflex fisiologis : .................................................................................
- Reflex patologis : .................................................................................
- Koordinasi otot : - tremor
- tonus
- porese
- paralyse
Page 4 of 6 G.46.0.73.04.01
Faal Paru :
- Foto thorax : ( lihat hasil pada lampiran )
- Spirometri : ( lihat hasil pada lampiran )
Elektrokardiogram : ( lihat hasil pada lampiran )
Treadmill test : ( lihat hasil pada lampiran )
Laboratorium : ( lihat hasil pada lampiran )
.................................................................................
VII. Ringkasan
Anamnesa
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Pemeriksaan medik :
- Fisik : .................................................................................
.................................................................................
- Mental : .................................................................................
.................................................................................
- Monitoring diagnostik ................................................................................
.................................................................................
.................................................................................
.................................................................................
.................................................................................
- Lain - lain : .................................................................................
.................................................................................
Pemeriksaan lingkungan / cara kerja
....................................................................................................................................
....................................................................................................................................
Waktu paparan nyata
....................................................................................................................................
....................................................................................................................................
(dr. .............................)
Page 6 of 6 G.46.0.73.04.01