Procedure

Last Name : ………………………….
Height : ………….Ft………..In……….
Sex : ……………………………………
Age : ………..
Passport No : ………………………
Position applied for : ……………………
History of any significant past illness including:
1.) Psychotic and neurological disorders
     (Epilepsy. depression. Schizophrenia……
 2.) Allergy         3.) Others

First Name :……………….
Wt …….    Lbs ………
Status : ……………..
Nationality : …………
Place of issue : ………..
Recruiting Agency…………………….

I hereby permit the………………..and the undersigned physician to furnish such information the company pertaining to my health status and other pertinent and medical findings and do hereby release them from any and all legal from my employment benefits and claims.

Signature of Examinee  ……………………….                                                  

RESULTS

                                         Rt
EYE …………. ……….
                                        Lt

                                        Rt
EAR …………………..
                                       
EAR …………………..
                                        Lt

SYSTEM EXAM
       CARDIO-VASCULAR
       B.P………………
       HEART…………….
 

RESPIRATORY SYSTEM
      LUNGS……………
      CHEST X-RAY
 

GASTRO INTESTINAL
          ABDONEN
  OTHERS
 

HERNIA

VARICOSE VEINS

EXTREMITIES

DEFORMITIES

SKIN

VENEREAL DISESES
          CLINICAL

C N S

PSYCHIATRY

TYPE OF LAB INVISTIGATONS

RESULTS

URINE
             SUGAR                          
             ALBUMIN
             BILHARZIASIS
            (IF ENDEMIC)

STOOL
            ROUTINE
1.        HELMINTHES
2.        GIARDIA
3.        BILHARGIASIS (IF ENDAIC CULTURE)
4.        SALMONELLA
         SHEGELLA
                V CHOLERA (IF ENDEMIC)

BLOOD
               HAEMOGLOBIN
               THICKFILM FOR
1.        MALARIA
2.        MICRO FILARIA

SEROLOGY
1.        F B S
2.        SGOT, SGPT
3.        CREATINNE
4.     S - BILIRABIN

ELISA
1.        HIV 1.2 TEST
2.        HBs Ag
3.        Anti HCV

VDRL
  TPHA  (IF VDRL POSITIVE)
     

PREGNANCY TEST