DOLE/BWC/OHSD/OH-47 A

Republic of the Philippines

Department of Labor and Employment
Bureau of Working Conditions
Occupational Health and Safety Division

ANNUAL MEDICAL REPORT FORM

For Period _________________ 20____ to ___________________ 20_______

_________________________________________________________________________________________
_________________________________________________________________________________________
1. Name of Establishment:
___________________________________________________________________________
2. Address:
_______________________________________________________________________________________
3. Name of Owner/Manager:
_________________________________________________________________________
4. Nature of Business and Products/Service (Ex. Manufacturing, Textile)
_________________________________________________________________________________________
5. Total Number of Employees: __________ Number of Shifts:
_______________________________________________
6. Number Distribution of Employees as to nature of workplace, sex and workshift
Office Production/Shop
1st Shift 2nd Shift 3rd Shift
Male: ____________________ _______________ _____________ _______________
Female: __________________ _______________ _____________ _______________
Total: ____________________ _______________ _____________ _______________
7. Preventive Occupational Health Services: (Check or Cross)
a. Occupational Health Services is organized/provided by:
( ) the establishment/undertaking
( ) government authority/institution
( ) other bodies/groups/institution (specify) _______________________________________________________
_________________________________________________________________________________________
b. Occupational Health services as described under 8a above, is organized/provided as a service:
( ) solely for the workers of the establishment/undertaking
( ) common to a number of establishments/undertakings
c. The employer engages the services of:
( ) Occupational health practitioner
Name: __________________________________________________________________________________
Address: ________________________________________________________________________________
( ) Occupational health physician
Name: __________________________________________________________________________________
Address: ________________________________________________________________________________
( ) Occupational health nurse
Name: __________________________________________________________________________________
Address: ________________________________________________________________________________
d. The occupational health physician/practitioner/nurse/personnel conducts an inspection of the workplace:
( ) once every month ( ) once every three (3) months
( ) once every two (2) months ( ) once every six (6) months
( ) other details ____________________________________________________________________
8. emergency Occupational Health Services:
a. The employer provides a treatment room/medical clinic in the workplace with medicines and facilities:
( ) Yes _____________ ( ) No _________________
( ) others, please specify ______________________________________________________________________
_________________________________________________________________________________________
b. Schedule of attendance in the workplace:
Workshift
Occupational health physician: __________________________ hrs/day ___________________________
Occupational health practitioner: __________________________ hrs/day __________________________
Occupational health nurse: __________________________ hrs/day _________________________
-2-
c. Schedule of attendance of full-time first-aider:
( ) 1st workshift
( ) 2nd workshift
( ) 3rd workshift
d. The following occupational health personnel of this establishment have undergone training in occupational health
and
safety/first aid:
( ) occupational health physician
( ) occupational health nurse
( ) first-aider
( ) others, please specify _________________________________________________________________
___________________________________________________________________________________
9. Occupational Health Services:
a. The occupational health personnel of this establishment conducts regular appraisal of the sanitation system in the
Workplace:
( ) Yes ( ) No
b. Number of workers who underwent the following medical examinations:
Physical Exams X-rays Urinalysis
1. Pre-placement ______________ ________ __________
2. Periodic ______________ ________ __________
3. Return-to-work ______________ ________ __________
4. Transfer ______________ ________ __________
5. Special ______________ ________ __________
6. Separation ______________ ________ __________
Stool Exams Blood Test ECG Others
1. Pre-placement ______________ __________ __________ ________
2. Periodic ______________ __________ __________ ________
3. Return-to-work ______________ __________ __________ ________
4. Transfer ______________ __________ __________ ________
5. Special ______________ __________ __________ ________
6. Separation ______________ __________ __________ ________
10. Report of Diseases
a. Number of cases diagnosed/treated for the following diseases ((/ of X):
Male Female Total Number of Cases
Skin:
( ) allergy _____________ ____________ ____________
( ) dermatoses
( ) infection as folliculitis/ _____________ ____________ ____________
absecess/paronychia
( ) Others _____________ ____________ ____________
Head:
( ) migraine headache _____________ ____________ ____________
( ) 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 _____________ ____________ ____________
( ) Tonsillopharyngitis _____________ ____________ ____________
( ) Laryngitis _____________ ____________ ____________
( ) Others _____________ ____________ ____________
-3-
Male Female Total Number of Cases
Respiratory:
( ) Bronchitis _____________ ____________ ____________
( ) Pronchial Asthma _____________ ____________ ____________
( ) Pneumonia _____________ ____________ ____________
( ) Tuberculosis _____________ ____________ ____________
( ) Pneumoconiosos _____________ ____________ ____________
( ) Others _____________ ____________ ____________
Heart and Blood Vessel:
( ) Hypertension _____________ ____________ ____________
( ) Hypotension _____________ ____________ ____________
( ) Angina Pectoris _____________ ____________ ____________
( ) Myocardial Infarction _____________ ____________ ____________
( ) Vascular disturbances _____________ ____________ ____________
in extremeties due to
continuous vibration
( ) Others _____________ ____________ ____________
Gastrointestinal:
( ) Gastroenteritis/Diarrhea _____________ ____________ ____________
( ) Amoebiasis _____________ ____________ ____________
( ) Gastritis/Hyperacidity _____________ ____________ ____________
( ) Appendicitis _____________ ____________ ____________
( ) Infectious Hepatitis _____________ ____________ ____________
( ) Liver Cirrhosis _____________ ____________ ____________
( ) Hepatic Absecess _____________ ____________ ____________
( ) Cancer (Hepatic/Gastric) _____________ ____________ ____________
( ) Others _____________ ____________ ____________
Genito-Urinary:
( ) Urinary Tract Infection _____________ ____________ ____________
( ) Stones _____________ ____________ ____________
( ) Cancer _____________ ____________ ____________
( ) Others _____________ ____________ ____________
Reproductive:
( ) Dysmenorrhea _____________ ____________ ____________
( ) Infection (Cervicitis) _____________ ____________ ____________
(Vaginitis) _____________ ____________ ____________
( ) Abortion (Spontaneous) _____________ ____________ ____________
(Threatened) _____________ ____________ ____________
( ) Hyperemesis Gravidarum _____________ ____________ ____________
( ) Uterine Tumors _____________ ____________ ____________
( ) Cervical Polyp/Cancer _____________ ____________ ____________
( ) Ovarian Cyst/Tumors _____________ ____________ ____________
( ) Sexually-Transmitted Diseases _____________ ____________ ____________
( ) Hernia (Inguinal) _____________ ____________ ____________
(Femoral) _____________ ____________ ____________
( ) Others _____________ ____________ ____________
Neuromuscular/Skeletal/Joints:
( ) Peripheral Neuritis _____________ ____________ ____________
( ) Torticollis _____________ ____________ ____________
( ) Arthritis _____________ ____________ ____________
( ) Others _____________ ____________ ____________
Lymphatics and Circulatory:
( ) Anemia _____________ ____________ ____________
( ) Leukemia _____________ ____________ ____________
( ) Cerebrovascular Accidents _____________ ____________ ____________
( ) Lymphadenitis _____________ ____________ ____________
( ) Lymphoma _____________ ____________ ____________
Infectious Diseases:
( ) Influenza _____________ ____________ ____________
( ) Typhoid/Paratyphoid Fever _____________ ____________ ____________
( ) Cholera _____________ ____________ ____________
( ) Measles _____________ ____________ ____________
-4-
Male Female Total Number of Cases
( ) Mumps _____________ ____________ ____________
( ) Tetanus _____________ ____________ ____________
( ) Malaria _____________ ____________ ____________
( ) Schistosomiasis _____________ ____________ ____________
( ) Herpes Zoster _____________ ____________ ____________
( ) Chicken Fox _____________ ____________ ____________
( ) German Measles _____________ ____________ ____________
( ) Rabies _____________ ____________ ____________
( ) Others _____________ ____________ ____________
Diseases due to Physical Environment:
( ) Diseases due to abnormalities _____________ ____________ ____________
in temperature and humidity
( ) Diseases due to abnormalities _____________ ____________ ____________
in air pressure
( ) Poisoning/Overdosage to _____________ ____________ ____________
Chemicals
TOTAL NUMBER . . . . . . . . . . . _____________ ____________ ____________
11. Report of Occupational Accidents/Injuries
Parts of Body Affected
Nature Male Female Total Number of Cases
Contussion, bruises, hematoma _____________ ____________ ____________
Abrasions _____________ ____________ ____________
Cuts, Lacerations, punctures _____________ ____________ ____________
Concussion _____________ ____________ ____________
Avulsion _____________ ____________ ____________
Amputation, loss of body parts _____________ ____________ ____________
Crushing injuries _____________ ____________ ____________
Spinal injuries _____________ ____________ ____________
Cranial injuries _____________ ____________ ____________
Sprains _____________ ____________ ____________
Dislocation/Fractures _____________ ____________ ____________
Chemical Burns _____________ ____________ ____________
12. Immunization Program (Indicate the number)
Tetanus Taxoid Injection _____________ ____________ ____________
Tetanus Antitoxin Injection _____________ ____________ ____________
Tetanus Globulin Injection _____________ ____________ ____________
Anti-Cholera, Anti-Typhoid Triple Vaccine _____________ ____________ ____________
Others (Please specify) _____________ ____________ ____________
13. Keeping of Medical-Records of Workers (Please check) ( ) done ( ) not done
14. Health Education and Counselling by Health and Safety Personnel:
(Please check one or more)
( ) done individually 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.
15. Other Health Programs
Use of Visual Aid/
Seminar Materials Counselling
Nutrition Program
Maternal and Childcare Program
Family Planning Program
Mental Health Activities
Personal Health Maintenance
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Physical Fitness Program: (Please check)
Sports Activities ( ) Yes ( ) No
Recreation Activities ( ) Yes ( ) No
Others (Please specify) ( ) Yes ( ) No
16. Hazards in the Workplace: (Please check and give details of the active substance)
Substances and/or Sources Number of Workers Exposed
a. Chemicals Hazards:
( ) dust (Ex. Silica dust) ______________________ ______________________
( ) liquids (Ex. Mercury) ______________________ ______________________
( ) mist/fumes/vapors
(Ex. Mist from paint spraying) ______________________ ______________________
( ) gas (Ex. CO, H2S) ______________________ ______________________
( ) others (please specify) ______________________ ______________________
b. Physical Hazards:
( ) noise ______________________ ______________________
( ) temperature/humidity ______________________ ______________________
( ) pressure ______________________ ______________________
( ) illumination ______________________ ______________________
( ) radiation/ultraviolet/microwave ______________________ ______________________
( ) others (please specify) ______________________ ______________________
c. Biological Hazards:
( ) Viral ______________________ ______________________
( ) Bacterial ______________________ ______________________
( ) Fungal ______________________ ______________________
( ) Parasitic ______________________ ______________________
( ) Others ______________________ ______________________
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