MEDICAL CHECKUP REPORT

First name:
Middle name:
Last name:
DOB:

Day

Month

Year

Company:
Site:
Date of MCU:

FINDINGS/DIAGNOSIS
1.

FITNESS TO WORK ASSESSMENT

Choose an item.

RECOMMENDATIONS
1.

MMCU Team:
Examining doctor
:
Cardiologist
:
Radiologist
:
Verification doctor
:

dr. Felicia Setiawan

dr. Rina Ariani, Sp.JP
dr. Tektona, Sp.Rad
dr. Florentina Marwisitaningrum

Patients name ID - Company

Page 1

dr. Indah Pratiwi Ersanty

CURRENT COMPLAINT
None significant

FAMILY MEDICAL HISTORY

Father
Yes

Mother
No

Yes

No

Live
Cause

Cause

Hypertension
Diabetes
Cardiovascular
diseases
Cancer
Asthma
Other diseases

None significant

Patients name ID - Company

None significant

Page 2

PERSONAL PAST MEDICAL HISTORY

Past surgical history:

None significant

Past medical history:

None significant

Chronic diseases:

None significant

Past trauma history:

None significant

SMOKING
Number of cigarettes per day:
Number of years smoking:
Pack-year:

0
0
0

ALCOHOL
Number of doses per week:
Number of sittings per week:

0
0

ALLERGIES
None significant

Patients name ID - Company

Page 3

TRIAGE

Blood Pressure:

Respiratory rate:

/mn

mmHg

Cardiac frequency:

/mn

Temperature:
Weight:

Celsius
kg

Height:

cm

Body Mass Index:

kg/m2

Female employees only:

Abortus
-

LMP:

Cycle:

Patients name ID - Company

Gravida

Page 4

Para

PHYSICAL EXAMINATION
HEAD EXAMINATION
- Scalp
- Hair
-

Abnormal
Abnormal

Eye Physical examination

Abnormal

Normal
Normal
Normal

If abnormal

ENT EXAMINATION
-

Nose

Abnorm
al

Norma
l

Abnorm
al

Norma
l

Abnorm
al

Norma
l

Abnorm
al

Norma
l

Abnorm
al

Norma
l

If abnormal
-

Right ear
o Drum

If abnormal
Canal
If abnormal

Left ear
o Drum

If abnormal
Canal
If abnormal

Throat

Normal

NECK EXAMINATION
-

Lymph nodes

Abnorm
al

Norma
l

Abnorm
al

Norma
l

If abnormal
-

Thyroid
If abnormal

Patients name ID - Company

Page 5

Carotid pulses

Abnorm
al

Norma
l

If abnormal

Patients name ID - Company

Page 6

CARDIOVASCULAR EXAMINATION
- Pulse:
o Facial artery
Well
o Carotid artery
Well
o Brachial artery
Well
o Radial artery
Well
o Femoral artery
Well
o Popliteal artery
Well
o Posterior tibial artery Well
o Dorsalis Pedis artery Well
- Bruits:

Carotid

Femoral

perceived
perceived
perceived
perceived
perceived
perceived
perceived
perceived

Ye
s
Ye
s

N
o
N
o

Heart sounds auscultation:

o

S1

S2

S3/S4

Murmur

Ye
s
Ye
s
Ye
s
Ye
s

N
o
N
o
N
o
N
o

If yes
-

Ye
s

Signs of cardiac failure

N
o

If yes

RESPIRATORY EXAMINATION
-

Ronchi

Yes

N
o

Yes

N
o

Yes

No

Yes

If yes
-

Wheezes
If yes

Stridor
If yes

Fine crackles

Patients name ID - Company

Page 7

o
If yes
-

Coarse crackles

Yes

N
o

Unequ
al

Equa
l

If yes
-

Air entry

Patients name ID - Company

Page 8

ABDOMINAL EXAMINATION
-

Hernias
o

Umbilical

Yes

N
o

Yes

N
o

Yes

N
o

Yes

N
o

Yes

N
o

Yes

N
o

Abnorm
al

Norma
l

If yes
o

Femoral
If yes

Inguinal
If yes

Tenderness
If yes

Mass
If yes

Organomegaly
If yes

Bowel sounds

DIGITAL RECTAL EXAMINATION

Performed

Refused

If performed

Patients name ID - Company

Page 9

Blood
Yes

No

Rectal Tumor
Yes

No

Hemorrhoids
Yes

No

Fissure
Yes

No

Prostate (male only)

Patients name ID - Company

Page 10

Consistency

Hands

Abnormal

Normal

If abnormal

Feet

Abnormal

Normal

If abnormal
Patients name ID - Company

Page 11

Patients name ID - Company

Page 12

NEUROLOGICAL
EXAMINATION
-

Cranial nerves

Abnorm
al

Norma
l

If abnormal
-

Reflexes
o Brachioradialis
o Biceps
o Triceps
o Patellar
o Achilles

+
+
+
+
+

Tone
Power
Sensations

Normal
Normal
Normal

BREAST EXAMINATION
(FEMALE)
If performed
Mass
If yes

SKIN EXAMINATION:

Perform
ed

Refuse
d

Yes

No

Normal

MOUTH AND DENTAL

-

Hygiene

Caries

Missing tooth

Pulp gangrene

Radix

Dentures

Crown/Bridge/Jacke
t
Calculus

Adequate

Patients name ID - Company

Page 13

Dental impaction

Others

MEDICAL INVESTIGATIONS

CHEST X-RAY:

Normal

If abnormal:

ELECTROCARDIO
GRAM:

Normal

If abnormal:

Patients name ID - Company

Page 14

LABORATORY REPORT

Parameter

Result

Reference
Range

Unit

HEMATOLOGY
White Blood Cell
Click here to enter
4.8-10.8
x 1000/mm3
(WBC)
text.
White Blood Cell (WBC), also called leukocytes or leucocytes, are the cells of
the immune system that are involved in defending the body against
both infectious disease and foreign invaders. The number of leukocytes in
the blood is often an indicator of disease. An increase in the number of
leukocytes over the upper limits is called leukocytosis, and a decrease below
the lower limit is called leukopenia.

Red Blood Cell (RBC)

Click here to enter

text.

M : 4.7-6.1
F : 4.2-5.4

x
1000.000/m
m3

Red Blood Cells (RBC) are the major component of your blood their main
fuction is to carry oxygen from the lungs to the bodys tissues and to transfer
carbon dioxide (a normal cells waste product) from the tissues to the lungs to
be breathed out. Low red blood cell count indicates anemia.
Click here to enter
M : 14-18
Hemoglobin
g / dL
text.
F : 12-16
Hemoglobin (Hb) is the actual oxygen-carrying component of red blood cells.
Iron is necessary for hemoglobin production. In Iron-deficiency anemia, low
blood Iron levels means that there is less available hemoglobin in the blood
to deliver oxygen to your bodys tissues.
Click here to enter
M : 42-52
Hematocrit (Hct)
%
text.
F : 37-47
Hematocrit (Hct) Red blood cells comprise, on average, about 45% of the
blood total volume. This percentage is called the hematocrit. Women
generally have lower hematocrit than do men. A low hematocrit signifies
anemia.
Thrombocyte
Click here to enter
150-450
x 1000/mm3
(Platelet)
text.
Thrombocytes (Platelets) are blood cells whose functions (along with
the coagulation factors) are to stop bleeding. The main function of platelets is
to contribute to hemostasis.
MCV

Click here to enter

text.

Patients name ID - Company

Page 15

79-99

mcm3

MCV (Mean Corpuscular Volume) Your MCV is the volume of your average
red blood cell. In some types of anemia, the MCV is abnormally small and in
others it is abnormally large. Your MCV, therefore, is the basis of classification
used in the evaluation of anemia.
Click here to enter
MCH
27-34
pg
text.
MCH (Mean Corpuscular Hemoglobin) Your MCH is amount of hemoglobin in
your average red blood cell. The MCH value aids in the diagnosis of anemia.
Click here to enter
MCHC
33-37
g/dL
text.
Click here to enter
Basophils
0-1
%
text.
Basophils Granular leukocytes characterized by a relative pale staining.
Click here to enter
Eosinophils
1-3
%
text.
Eosinophils a type of polymorphonuclear leukocyte containing eosinstaining granules. Although the activity of eosinophils is not entirely clear,
they are known to destroy parasitic organism and play a major role in allergic
reaction.
Neutrophil
Click here to enter
50-70
%
Segmented
text.
Neutrophils The major type of white blood cells are neutrophils,
lymphocytes, monocytes, and basophils.
Click here to enter
Lymphocytes
20-40
%
text.
Lymphocytes white blood cells that fight infection and disease
Click here to enter
Monocytes
2-8
%
text.

Patients name ID - Company

Page 16

BLOOD CHEMISTRY
ALT (SGPT)

Click here to enter

text.

M : Up to 40
F : Up to 32

U/L

ALT (Alanine Transaminase) is enzyme that is located primarily in your liver.

Significant elevations suggest liver disease.
AST (SGOT)

Click here to enter

text.

M : Up to 38
F : Up to 31

U/L

AST (Aspartate Transaminase) is enzyme concentrated mainly in your hearth

and liver. Increased blood levels occur with heart, liver and muscle damage.
Normal : < 100
Impaired
Click here to enter
Glucose Fasting
Fasting Glucose
mg/dL
text.
: 100-125
DM : > 126
Glucose Glucose is a simple sugar that is formed from carbohydrate
digestion. Glucose provides energy to the cells of your body. The main uses of
glucose testing are in the diagnosis of diabetes and in the monitoring
treatment for this condition.
Click here to enter
Cholesterol Total
<200
mg/dL
text.
Cholesterol is a lipid (Fatty) substance that is used by the body in the
formation of cells membrane, bile acids, and hormones. Your body actually
makes the cholesterol it needs and sometimes more than it needs. Excess
cholesterol, wether from dietary source or because of increased production,
can build up in your arteries and cause hearth disease. Measurement of blood
cholesterol levels is used to evaluate and classify the risk of coronary hearth
disease.
Ureum

15-45

mg/dL

BUN (Blood Urea Nitrogen) is a normal waste product of protein metabolism.

Because BUN is excreted by kidney, the clearance of this substance from
your blood is used to evaluate your kidney function. BUN is non specific test
of kidney function since it can be elevated with dehydration, high protein
intake, and other conditions.
Click here to enter
M : 0.7-1.4
Creatinine, Serum
mg/dL
text.
F : 0.6-1.1
Creatinine is cleared from the blood by the kidneys. Elevation in creatinine
can indicate kidney disease.
Click here to enter
M : Up to 7.7
Uric Acid, Serum
mg/dL
text.
F : Up to 6.8
High blood levels of uric acid in the body can cause a painful condition called

Patients name ID - Company

Page 17

gout. If gout remains untreated, uric acid crystals can build up in the joints
and nearby tissues, forming hard deposits called tophi. High levels of uric
acid in the urine can cause kidney stones.
HBs Ag

Non Reactive

Non Reactive

URINALYSIS
Macroscopic
Specific Gravity

Choose an item.

1.015

pH

Choose an item.

6.0

Blood

Negative

Negative

Leukocyte

Negative

Negative

Nitrites

Negative

Negative

Protein

Negative

Negative

mg/dL

Glucose

Negative

Negative

mg/dL

Keton

Negative

Negative

mg/dL

Urobilinogen

Normal

3.2-16

umol/L

Bilirubin

Negative

Negative

mg/dL

Microscopic
Blood

Negative

Negative

Leukocyte

Negative

Negative

Cylinders

Negative

Negative

Epithelia

Negative

Negative

Bacteria

Negative

Negative

Crystal

Negative

Negative

Others

Negative

Negative

Patients name ID - Company

Page 18

/uL