• STATUTORY MEDICAL EXAMINATION FORM

  • This questionnaire will only be used for purpose of assessing fitness to work with Statutory Exposures according to Ministry of Manpower (MOM The questionnaire is secured and meets the US HIPAA (Health Insurance Portability & Accountability Act) requirements for Medical Data protection. A password protected copy of filled questionnaire will be emailed to you to print and bring down to clinic. 

  • Type of Statutory Medical*
  • Designation*
  • Date of Birth (required by MOM)*
     / /
    2 digit day, 2 digit month, 4 digit year
  • Type of Statutory Exposure*
  • Did you have any incidents resulting in accidental exposure in the lab/at work in the past 1-3 years?
  • Date of Start of Exposure*
     - -
    2 digit day, 2 digit month, 4 digit year
  • What other lab hazards are you exposed to?
  • Do you have the following conditions?*
    Rows
  • If exposed to noise, do you use ear plugs/ear muffs when working in noisy area?
  • Do you smoke?
  • Date of most recent Chest Xray
     / /
    2 digit month, 2 digit day, 4 digit year
  • Declaration*
  • Date*
     / /
    2 digit day, 2 digit month, 4 digit year

  • TO BE FILLED BY DOCTOR ONLY

  • PHYSICAL EXAMINATION (RELEVANT SYSTEMIC REVIEW)
    Rows
  • Audiogram Result
    Rows
  • Hearing Results
  • Other Results
    Rows
  • Chest Xray, Liver Function Tests, Skin Examination
  • Full Blood Count and Peripheral Blood Film
  • Liver Function

  • Reference:

    Blood Lead (Female Upper limit 30 ug/dL; Male Upper limit 50 ug/dL), Haemoglobin (Female More than 11.5g%, Male More than 13.5g%)
    Urine Manganese Upper Limit 50.01 ug/L

    Urine Arsenic Upper Limit 300.01 ug/L

    Blood Cadmium (Less than 5.01 ug/L), Urine Beta 2 Microglobulin (Less than 288 ug/gm Creatinine)

    Urine Mercury Upper Limit 50.1 ug/L

    Urine Trans, Trans-Muconic Acid 1.6mg/gm Creatinine

    Urine Trichloroethylene (Exposure to Trichloroacetic Acid) Upper Limit 100mg/L

     

  • Presence of deterioration of results compared with previous tests (if any):
  • Validity
  • Date
     - -
    2 digit day, 2 digit month, 4 digit year
  • Time
  • Should be Empty: