| WORKPLACE | |||||||||||||||||
| Title | |||||||||||||||||
| SSI Registry No. | |||||||||||||||||
| Address | |||||||||||||||||
| Tel and fax | |||||||||||||||||
| I hereby declare that I agree to be examined at the initial/periodic examination and that the information I have provided during the examination is correct and complete. Name and Surname of Employee SIGNATURE ——————————————————————————————————————————– EMPLOYEE | |||||||||||||||||
| Name and surname | |||||||||||||||||
| T.C.Identity No | |||||||||||||||||
| Place and Date of Birth | |||||||||||||||||
| Gender | |||||||||||||||||
| Education status | |||||||||||||||||
| Marital status | Child No. | ||||||||||||||||
| Home Address | |||||||||||||||||
| Tel No./e-mail | |||||||||||||||||
| Profession | |||||||||||||||||
| His/her job (To be defined in detail) | |||||||||||||||||
| Department he/she works in | |||||||||||||||||
| Previous places of employment (From today to the past) | Line of Business | Performed Duty | |||||||||||||||
| 1. | |||||||||||||||||
| 2. | |||||||||||||||||
| 3. | |||||||||||||||||
| History | |||||||||||||||||
| Blood group | |||||||||||||||||
| Congenital/chronic disease | |||||||||||||||||
| Immunisation | |||||||||||||||||
| – Tetanus | |||||||||||||||||
| – Hepatitis | |||||||||||||||||
| – Other | |||||||||||||||||
| Family history (chronic diseases, immunisation) | |||||||||||||||||
| Mother | Father | Sibling | |||||||||||||||
| MEDICAL ANAMNESIS | |||||||||||||||||
| 1. Have you experienced any of the following complaints? | No | ||||||||||||||||
| – Cough with phlegm | |||||||||||||||||
| – Shortness of breath | |||||||||||||||||
| – Chest pain | |||||||||||||||||
| – Palpitations | |||||||||||||||||
| – Back pain | |||||||||||||||||
| – Diarrhoea or constipation | |||||||||||||||||
| – Pain in the joints | |||||||||||||||||
| 2. Have you ever had any of the following diseases? | No | ||||||||||||||||
| – Heart disease | |||||||||||||||||
| – Diabetes | |||||||||||||||||
| – Kidney disease | |||||||||||||||||
| – Jaundice | |||||||||||||||||
| – Stomach or duodenal ulcer | |||||||||||||||||
| – Hearing loss | |||||||||||||||||
| – Visual impairment | |||||||||||||||||
| – Nervous system disease | |||||||||||||||||
| – Skin disease | |||||||||||||||||
| – Food poisoning | |||||||||||||||||
| 3. Have you been hospitalised? | No | If yes, diagnosis? | |||||||||||||||
| 4. Have you had an operation? | No | If yes, why? | |||||||||||||||
| 5. Have you had a work accident? | No | If yes, what happened? | |||||||||||||||
| 6. Have you been subjected to examinations and examinations related to suspected occupational diseases? | No | If yes, the result? | |||||||||||||||
| 7. Have you received a disability? | No | If yes, what is it and the rate? | |||||||||||||||
| 8. Are you currently receiving any treatment? | No | If yes, what is it? | |||||||||||||||
| 9. Are you smoking? | No | ||||||||||||||||
| Quitted | Before……….month/year | Smoked………….month/year | |||||||||||||||
| Yes | Since……….yıldır | …………..piece/day | |||||||||||||||
| 10. Do you drink alcohol? | No | ||||||||||||||||
| Quitted | Before …………..years | Drank…………..eyars | |||||||||||||||
| Yes | Since……….year | …………..frequency | |||||||||||||||
| PHYSICAL EXAMINATION RESULTS | |||||||||||||||||
| a) Sense organs | |||||||||||||||||
| – Eye | |||||||||||||||||
| – Ear-Nose-Throat | |||||||||||||||||
| – Leather | |||||||||||||||||
| b) Cardiovascular system examination | |||||||||||||||||
| c) Respiratory system examination | |||||||||||||||||
| d) Digestive system examination | |||||||||||||||||
| e) Urogenital system examination | |||||||||||||||||
| f) Musculoskeletal examination | |||||||||||||||||
| g) Neurological examination | |||||||||||||||||
| Ğ) Psychiatric examination | |||||||||||||||||
| h) Other | |||||||||||||||||
| -TA : / mm-Hg | |||||||||||||||||
| -Nb : / min. | |||||||||||||||||
| -Height: Weight: Body Mass Index : | |||||||||||||||||
| LABOUR FINDINGS | |||||||||||||||||
| a) Biological analyses | |||||||||||||||||
| – Blood | |||||||||||||||||
| – Urine | |||||||||||||||||
| b) Radiological analyses | |||||||||||||||||
| c) Physiological analyses | |||||||||||||||||
| – Audiometer | |||||||||||||||||
| – SFT | |||||||||||||||||
| d) Psychological tests | |||||||||||||||||
| e) Other | |||||||||||||||||
OPINION AND CONCLUSION * :
1- …………………………………………………………………………………………………………………………………… is physically and mentally fit for work.
2- ………………………………………………………………………………………………………………….. is suitable to work with the condition.
(*As a result of the examination, it will be stated whether the employee can work in night or shift working conditions and whether the employee is suitable for working with these conditions if there is a suitable tool, equipment, etc. complementing the health and integrity of the body…)
SIGNATURE
Name and Surname : ………… / …………. / 20………….
Diploma Date and No:
Diploma Registration Date and No:
Workplace Medicine Certificate Date and No:
