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LAPORAN UJI KESEHATAN FISIK

KARYAWAN

Pekela

NO :

Saya yang bertanda tangan dibawah ini :

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.

Dokter yang memeriksa, Cikarang, ………….

Tanda tangan Karyawan

( ............................ ) (…………………………………)

*) Coret yang tidak perlu

(Hasil anamnesa di bawah ini diisi oleh dokter pemeriksa / perawat yang berwenang)
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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 : .................................................................................
.................................................................................
.................................................................................

III. Pemeriksaan Fisik

Tinggi badan : .................................................................................
Berat badan : .................................................................................
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Berat badan ideal : .................................................................................

Denyut nadi : .................................................................................
Tensi : Sistole .....................................................................
Diastole ...................................................................
Kesan umum :
- Respiratory : .................................................................................
.................................................................................
- Kulit : .................................................................................
.................................................................................
- Pendengaran : .................................................................................
.................................................................................
- Muskuloskeletal : .................................................................................
.................................................................................
- Psyche : .................................................................................
.................................................................................
Kepala : .................................................................................
Leher :
- Kelenjar lymphe : .................................................................................
- Kelenjar thyroid : .................................................................................
Thorax :
- Paru - paru : .................................................................................
- Jantung : .................................................................................
Abdomen : .................................................................................
Hepar : .................................................................................
Lien : .................................................................................

Alat reproduksi : wanita pria

- Genitalia : .................................................................................
- Haid pertama umur : .................................................................................
- Haid teratur / tidak, siklus...........hari, sakit / tidak
- Haid terakhir tgl.........bln..........G.....P....A.....
- Keluarga berencana istri /suami
Jenis kontrasepsi sebelum ini .........................., tgl........bln.......thn...........
Jenis kontrasepsi sekarang .............................., tgl....... bln........thn..........
Jenis kontrasepsi yang akan datang ................., tgl........bln....... thn.........
Tanpa kontrasepsi ............................................, tgl........bln....... thn.........
- Lain-lain : ................................................................................
................................................................................

Extremitas :
- Reflex fisiologis : .................................................................................
- Reflex patologis : .................................................................................
- Koordinasi otot : - tremor
- tonus
- porese
- paralyse
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Mulut dan gigi :

Gigi geligi
O = karies X = tidak ada
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

IV. Test Diagnostik

Mata
- Visus : VOD .......................................................................
VOS .......................................................................

- Pemakaian kaca mata / lensa

Koreksi pertama tgl.......bln.......thn........
Koreksi terakhir tgl...... bln...... thn....... VOD VOS
PLQ ................................................
PD ...............................................
PPQ ................................................
Cyl ................................................
- Test buta warna : .................................................................................
Test pendengaran :
- Metode berbisik : .................................................................................
- Audiogram : ( lihat hasil pada lampiran )

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 )

V. Hasil Pemeriksaan Lingkungan Kerja & Cara Kerja

Pemeriksaan lingkungan / cara kerja
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Waktu paparan nyata :
- Per hari : ................................................................................
- Per minggu : ................................................................................
Alat pelindung diri : ................................................................................
................................................................................
................................................................................

VI. Pemeriksaan Kesehatan Sebelum Bekerja

Dilakukan / tidak dilakukan : .................................................................................
Kelainan yang diketemukan : .................................................................................
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.................................................................................
VII. Ringkasan
Anamnesa
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

Pemeriksaan medik :
- Fisik : .................................................................................
.................................................................................
- Mental : .................................................................................
.................................................................................
- Monitoring diagnostik ................................................................................
.................................................................................
.................................................................................
.................................................................................
.................................................................................
- Lain - lain : .................................................................................
.................................................................................
Pemeriksaan lingkungan / cara kerja
....................................................................................................................................
....................................................................................................................................
Waktu paparan nyata
....................................................................................................................................
....................................................................................................................................

VIII. Kesimpulan & Saran

(dr. .............................)
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IX. Tempelkan Lampiran Hasil Pada Lembaran Ini