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Republic of the Philippines Department of Labor and Employment National Capital Region
ANNUAL MEDICAL REPORT FORM
For Period January 1, _____ to December 31, _____
- Name of Establishment:__________________________________________________
- Address:______________________________________________________________
- Name of Owner/ Manager:________________________________________________
- Nature of Business & Product/ Service (Ex. Manufacturing – textile)_______________
- Total Number of Employee:_________ Number of Shift:________________________
- Number Distribution of Employee as to nature/workplace, sex & workship:
office Product/Shop 1 st^ Shift 2 nd^ Shift 3 rd^ Shift Male :___________ ___________ ______________ ____________ Female:__________ ___________ ______________ ____________ Total:___________ ___________ ______________ ____________
- Preventive Occupational Health Service: (Check or Cross)
a. Occupational health service is organized / provided by:
( ) the establishment / undertaking ( ) government authority / institution ( ) other bodies / group / institution ( specify )__________________________
b. Occupational health services as described under number 7a above, is organized / provided as a service :
( ) solely for the workers of the establishment / undertakings ( ) common to a number of establishment / undertakings
c. The employer engages the services of :
( ) Occupational health practitioner Name: ______________________________________________________ Address: ____________________________________________________ ( ) Occupational health physician Name: ______________________________________________________ Address: ____________________________________________________ ( ) Occupational health dentist Name: ______________________________________________________ Address: ____________________________________________________ ( ) Occupational health nurse Name: ______________________________________________________ Address: ____________________________________________________
d. The occupational health physician/practitioner/nurse/personnel conducts an inspection of the work place:
( ) once every month ( ) once every two (2) months ( ) once every three (3) months ( ) once every six (6) months ( ) other details: _________________________________________________
- Emergency Occupational Health Services:
a. The employer provides a treatment room/medical clinic in the work place with medicines and facilities
( ) Yes _________________ ( ) No __________________ ( ) others, please specify __________________________________________
b. Schedule of attendance in the work place: Work shift Occupational health physician :________ hrs./day___________ Occupational health dentist :________ hrs/day ___________
c. Schedule of attendance of full time first aider
( ) 1st^ work shift ( )2nd^ work shift ( ) 3rd^ work shift
- Report of Diseases
a. Number of consultations/treatments for the following diseases:
Male Female Total No. Of Cases Skin:
( ) Allergy ______ _______ __________ ( ) Dermatoses ______ _______ __________ ( ) Infection as folliculitis abscess/paronychia ______ _______ __________ ( ) Others ______ _______ __________
Head:
( ) Tension/headache ______ _______ __________ ( ) Others ______ _______ __________
Eyes:
( ) Error of refraction ______ _______ __________ ( ) Bacterial/Viral conjunctivities ______ _______ __________ ( ) Cataract ______ _______ __________ ( ) Others ______ _______ __________
Mouth & ENT:
( ) Gingivitis ______ _______ __________ ( ) Herpes Labiales/ nasalis ______ _______ __________ ( ) Otitis Media Externa ______ _______ __________ ( ) Deafness ______ _______ __________ ( ) Meniere”s Syndrome /Vertigo ______ _______ __________ ( ) Rhinitis/Colds ______ _______ __________ ( ) Nasal Polyps ______ _______ __________ ( ) Sinusitis ______ _______ __________ ( ) Tonsilio
pharyngitis ______ _______ __________ ( ) Laryngitis ______ _______ __________ ( ) Others ______ _______ __________
Respiratory:
( ) Bronchitis ______ _______ __________ ( ) Bronchial/Asthma ______ _______ __________ ( ) Pneumonia ______ _______ __________ ( ) Tuberculosis ______ _______ __________ ( ) Pneumoconiosis ______ _______ __________ ( ) Others ______ _______ __________
Heart and Blood Vessel:
( ) Hypertension ______ _______ __________ ( ) Hypotension ______ _______ __________ ( ) Angina Pectoris ______ _______ __________ ( ) Myocardial Infraction ______ _______ __________ ( ) Vascular disturbances in extremities due to continuous vibration ______ _______ __________ ( ) Others ______ _______ __________
Gastrointestinal:
( ) Casroenteritis/ Diarrhea ______ _______ __________ ( ) Amoebiasis ______ _______ __________ ( ) Gastritis/ Hyperacidity ______ _______ __________ ( ) Appendicitis ______ _______ __________ ( ) Infectious Hepatitis ______ _______ __________
- Keeping of Medical Records of Workers (Please Check)
( ) Done ( ) Not Done
- Health Education and Counseling by Health and Safety Personnel: (Please Check one or more)
( ) done individual as each worker comes to the clinic for consultation. ( ) done in organized group discussions/seminars. ( ) done with the use of visual displays and/or promotional materials, leaflets, etc.
- Other Health Programs (Please Check)
Kinds of Program Seminars Use of Visual Counseling id/Materials Nutrition Program ( ) ( ) ( ) Material and Child Care Program ( ) ( ) ( ) Family Planning Program ( ) ( ) ( ) Mental Health Activities ( ) ( ) ( ) Personal Health Maintenance ( ) ( ) ( )
Physical Fitness Program: (Please Check)
Sport Activities ( ) Yes ( ) No Others (Please Check) ( ) Yes ( ) No
- Hazard in the workplace : (Please check and give details of the substance)
Substance and/or Number of workers
sources exposed
a. Chemical Hazard: b. ( ) Dust (Ex. Silica dust) _____________ ________________ ( ) Liquid (Ex. Mercury) _____________ ________________ ( ) Mist/fumes/vapors (Ex. mist from paint spraying) _____________ ________________ ( ) Gas (Ex. CO, H2S) _____________ ________________ ( ) Others (please specify) (Ex. solvents) _____________ ________________
Physical Hazards
( ) Noise ( ) Temperature/humidity ( ) Pressure ( ) Illumination ( ) Radiation/ultraviolet/microwave ( ) Vibration ( ) Others (Please specify)
c. Biological hazard:
( ) Viral _____________ _________________ ( ) Bacterial _____________ _________________ ( ) Fungal _____________ _________________ ( ) Parasitic _____________ _________________ ( ) Others, specify _____________ _________________
d. Ergonomic Stress:
( ) Exhausting physical work _____________ _________________ ( ) Prolonged standing _____________ __________________ ( ) Low back pain _____________ __________________ ( ) Unfavorable work posture _____________ __________________ ( ) Static/monotonous work _____________ __________________ ( ) Others, specify _____________ __________________
Submitted by:
Medical Personnel/Title Date
Noted by:
Employer
