Occupational Health form

Occupational Health Assessment form
Examinations Date:
Saturday, August 17, 2024
Badge Number
KM-HSE-86
Name
Ranja Bakir Zahir
Date of Birth
Wednesday, June 7, 1995
Age
29.22
Department
HSE
Phone Number
(0000) 000-0000
Gender
Male
Designation
HSE Technician
Company
Crescent
Contractor Type
Permanent
LN/Expat
LN
Rotation Group
Group D
Type of examination
Occupational Health Assessments
Location of examination
KM-Clinic
Completed by the Employee
Do you suffer from any allergies.?
No
Past Surgical history?
No
Past Medical History?
No
Are you taking any medication(s) prescribed by a doctor?
No
Smoking Note
Do you Smoke?
Hukkah
1 - 10 Per-day
Do you drink alcohol?
No
Do you usually cough when you first get up or during the day?
No
Have you noticed wheeze in your chest in the past 3 years?
No
Do you experience shortness of breath?
No
Do you suffer from hypertension (high blood pressure)?
No
Have you ever suffered from, or do you currently suffer from, chest pain or discomfort?
No
Have you noticed any unintentional change in your weight recently (more than 5kg up or down)?
No
Have you noticed a change in your bowel movements/habits that have persisted for more than 6 weeks (e.g., tendency for constipation or diarrhea) or had dark or blood-stained stools?
No
Have you ever had neck pain or pain in your back that has kept you off work or caused you to be assigned alternative duties?
No
Have you ever had a shoulder, arm or hand injury that has kept you off work?
No
Have you ever had problems with any other joints which resulted in time off work or caused you to be assigned alternative duties?
No
Have you ever been diagnosed with a disease
or disorder of the nervous system?
No
Have you ever suffered blackouts (fainting) or seizures (fits)?
No
Have you ever been diagnosed with a psychiatric illness (including anxiety or depression)?
No
Have you noticed any changes in your hearing in the past three years?
No
Have you ever suffered episodes of numbness or weakness?
No
Have you had any Skin problems
Normal

I hereby declare that: -
My answers relating to my medical and employment history are true and complete.
I have read and understood the conditions on this form.
Information provided is confidential and remains the property of Khormor Medical Center.

  • رەزامەندبوون: من کە لە سەرەوە ناوم هاتووە، ئەو پرسیارانەی کە لێم کراوە(بۆم خوێندراوەتەوە) کە پایوەنادیان بە تەندروستیمەوە هەیە لە هەموو پرسیارەکان تێگەیشتوم و خوێندومەتەوەو هەموویم بە راستوودرووستی وەلام داوەتەوە، ئەو زانیاریانەی کە لەم فۆرمەدا هەیە بە نهێنی دەمێنێتەوە لە رەزامەندی دەردەبرم کە ئەم زانیاریانە بەکاربێن بۆ هەر کێشەیەک کە پایوەندی بە باری تەندروستیمەوە هەبێ
Decleration Signature: -
Item - signature 0
Completed by Examining Medical Officer Heading
Hight in CM
175
Weight in Kg
80
BMI
26.12
Systolic B. pressure mmhg
113
Diastolic B. pressure mmhg
78
BP Score
-0.35
Already on Blood pressure management
NO
Pulse Beat/M
76
Blood Sugar Mg/dl
111
Fasting Or random B. Sugar?
RBS
ON Diabetic Management ?
No
Lipid Profile
Triglyceride
121
Total Cholesterol
162
LDL
95
HDL
42
Non-HDL
120
LDL/HDL
2.28
Lipid profile
Fasting
Urine Examinations
Urine Color:
Yellowish to amber urine
Clarity
Clear
Glucose MG/DL
Negative
Bilirubin
Negative
Ketone
Negative
Blood
Negative
PH
5.0
Specific Gravity
>=1.030
Protien MG
Negative
Urobilinogen
0.2 E.U/dl
Nitrite
Negative
Leukocyte Esterase
Negative
Any other lab test.
Urine Examination attachement
General Examinations
Cardiovascular System: Medical Examiners Comments:
Normal
ECG
PDF
Ranja Bakir Zahir ECG.pdf
Vision: Medical Examiners Comments:
Normal
Vision Test result from Visiolite
Normal
Vision test attachment
PDF
Ranja Bakir Zahir Vision.pdf
Currently wearing prescription glasses
No
Lung Function(Spirometry) result from the Spirometer
Normal Spirometry
Spirometry
PDF
Ranja Bakir Zahir Spiro.pdf
Respiratory: Medical Examiners Comments:
Normal
Audiometry Category result from the Audiometer
HSE-CAT 1 (normal hearing)
Audiometry
PDF
Ranja Bakir Zahir Audio.pdf
Audiometry: Medical Examiners Comments:
Normal
Central Nervous System: Medical Examiners Comments:
INTACT
Abdominal Examination: Medical Examiners Comments:
Normal
Musculoskeletal System
Range of neck movements: Flexion, extension, lateral movement, and rotation
Normal
Range of shoulder movements: Rt & Lt. Flexion, extension, abduction, internal and external rotation
Normal
Range of elbow movements: Rt & Lt. Flexion, extension, pronation, and supination
Normal
Range of wrist movements: Rt & Lt. Flexion & extension
Normal
Hand grips: Rt & Lt.
Normal
Upper limb power of resisted flexion and extension: Rt & Lt.
Normal
Range of back movements: Flexion, extension, lateral movement, and rotation
Normal
Power of dorsiflexion in each foot: (e.g. ability to sustain standing on each foot independently for 10 seconds)
Normal
Any back pain at the moment?
No
Musculoskeletal System general Notes
Normal
Dr. Recommendations
Pass
Review Appointments.
Review status
Referral attachments
Referrals
No Need
Dr.
Younis M.
Examining Medical Officer:
Rizgar J.
Next Medical Date
Sunday, August 17, 2025
Search Badge N.
KM-HSE-86
ProgressBar
Health Results Summary
Assessment Date
Name
Ranja Bakir Zahir
Date of birth
Wednesday, June 7, 1995
Phone Number
(000) 000-0000
Department
Hight:
Weight:
Body Mass Index
26.12
Blood Pressure
Non-HDL
Total Cholesterol
LDL:
Total Cholesterol Ratio:
HDL:
Lung Age
Triglyceride:
Diabetes Score
Framingham Risk Score
0
About this template
Categories
Details
11 Clone
Created by
Roadam
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