demo-form - Berkat OSH Services Sdn Bhd

Name

Email

NRIC/Passport

Age

Occupation

Company Name

Company Address

Sinus Trouble

Yes No

Neck Swelling/Gland

Yes No

Difficulty in Vision

Yes No

Any Ear Discharge

Yes No

Bronchial Asthma / Bronchitis

Yes No

Hay fever / Other allergy

Yes No

Any skin trouble

Yes No

Tuberculosis

Yes No

Coughed / Vomited blood

Yes No

Severe abdominal pain

Yes No

Stomach Ulcer

Yes No

Recurrent indigestion

Yes No

Jaundice or hepatitis

Yes No

Gall Bladder disease

Yes No

Marked change in bowel habits

Yes No

Blood in stools (motions)

Yes No

Dental Problem

Yes No

Piles (Haemorroid)

Yes No

Hernia

Yes No

Varicose Veins

Yes No

Lump in breast / arm pit

Yes No

Cancer

Yes No

Heart disease

Yes No

Rheumatic fever

Yes No

Abnormal heartbeat

Yes No

High blood pressure

Yes No

Stroke

Yes No

Serious chest pain

Yes No

Any blood disease

Yes No

Painful passage of urine

Yes No

Blood in urine

Yes No

Diabetes

Yes No

Blood in urine

Yes No

Headache / Migraine

Yes No

Dizziness / fainting

Yes No

Epilepsy

Yes No

Joint/spinal trouble

Yes No

Surgical operation

Yes No

Serious accident / injury

Yes No

Tropical disease

Yes No

Fear of heights

Yes No

Fear of being enclosed in a small space

Yes No

Currently taking Any medication?

Yes No

Have You Ever Been:

Rejected for employment or insurance

Yes No

Awarded benefits for Industrial injury/ illness

Yes No

Treated for problem of mental condition

Yes No

Treated for problem of alcohol or drug

Yes No

Exposed to toxic substances or noise

Yes No

WOMEN ONLY - Have You Ever Had:

Abnormal Pap smear

Yes No

Any gynecological condition / treatment

Yes No

Are you pregnant

Yes No

Will you be doing any of these specific activities?

Crane Operators

Yes No

Catering Crew

Yes No

Confine Space Entry

Yes No

Working at Height

Yes No

Social History

Do you smoke?

Yes No

History of drug abuse

Yes No

Do you drink alcohol?

Yes No

Have you been medical disembarked from offshore within the past 2 years?If yes, please specify:

Yes No

Other illness not mentioned above. If yes, please specify:

Have any of your family members suffered from the following?

Diabetes

Yes No

Tuberculosis

Yes No

Bronchial Asthma

Yes No

Heart Disease

Yes No

Cancer

Yes No

Hypertension

Yes No

Stroke

Yes No

Blood Disease

Yes No