Annual Medical Report 4m461d

DOLE/BWC/HSD/OH-47-A

Republic of the Philippines DEPARTMENT OFLABOR AND EMPLOYMENT National Capital Region ANNUAL MEDICAL REPORT FORM For Period January 1, 2015 to December 31, 2015 1. Name of Establishment: ___MARYSVILLE BOARDING HOUSE_____________________________ 2. Address: __________1452 SH Loyola St., Sampaloc, 045 Bgy 457, Manila______________________ 3. Name of Owner/Manager: ________Anita F. Carbonel______________________________________ 4. Nature of Business and Production/Service (Ex. Manufacturing Textile): ____________________ ____________________Dormitory / Boarding House_______________________________________ 5. Total Number of Employees: _______4__________ Number of Shifts: _____1________________ 6. Number Distribution of Employees as to nature/workplace, sex and workshift: Office Production/Shop 1st Shift Male : ___1______ Female: ___3______ Total : ___4______

____1_____ ____3_____ ____4_____

2nd Shift __________ __________ __________

3rd Shift __________ __________ __________

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 number 7a 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 dentist 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: Work shift Occupational health physician Occupational health dentist Occupational health practitioner Occupational health nurse c.

: ________________ hrs./day _____________ : ________________ hrs./day _____________ : ________________ hrs./day _____________ : ________________ hrs./day _____________

Schedule of attendance of full time first aider: ( ) 1st work shift ( ) 2nd work shift ( ) 3rd work shift

d. The following occupational health personnel of the establishment have undergone training in occupational health and safety/first aid: ( ) occupational health physician ( ) occupational health dentist ( ) 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 examination: Physical Exam X-Rays Urinalysis 1. Pre-placement ______________ _____________ ________________ 2. Periodic ______________ _____________ ________________ 3. Return-to-work ______________ _____________ ________________ 4. Transfer ______________ _____________ ________________ 5. Special ______________ _____________ ________________ 6 Separation ______________ _____________ ________________ 1. 2. 3. 4. 5. 6.

Pre-placement Periodic Return-to-work Transfer Special Separation

Stool Exam __________ __________ __________ __________ __________ __________

Blood Test __________ __________ __________ __________ __________ __________

ECG ________ ________ ________ ________ ________ ________

Others __________ __________ __________ __________ __________ __________

10. Report of Diseases: a. Number of consultations/treatments for the following diseases: Male

Female

Total Number of Cases

Skin: ( ( (

) ) )

_______ _______

_______ _______

___________ ___________

)

allergy dermatoses infection as folliculitis abscess/paro nychia Others

(

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( (

) )

tension headache Others

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( (

) )

error of refraction bacterial/viral conjunctivities cataract Others

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Head: Eyes:

( ) ( ) Mouth & ENT: ( ) Gingivitis ( ) Herpes labiales/nasalis ( ) Otitis Media/Externa ( ) Deafness ( ) Menlere’s Syndrome/Vertigo ( ) Rhinitis/Colds ( ) Nasal Polyps ( ) Sinusitis ( ) Tonsillopharyngitis ( ) Laryngitis ( ) Others Respiratory: ( ) Bronchitis ( ) Bronchial asthma ( ) Pneumonia ( ) Tuberculosis ( ) Pneumoconiosis ( ) Others Heart and Blood Vessel: ( ) Hypertension ( ) Hypotension ( ) Angina Pectoria ( ) Myocardial Infraction ( ) Vascular disturbances in extremeties due to continuous vibration ( ) Others Gastrointestinal: ( ) gastroenteritis/darrhea ( ) amoebiasis ( ) gastritis/hyperacidity ( ) appendicitis ( ) infectious hepatitis ( ) liver cirrhosis ( ) hepatic abscess ( ) cancer (hepatic/gastric) ( ) ulcer ( ) Others

Genito Urinary: ( ) Urinary tract infection ( ) Stones ( ) Cancer ( ) Others Reproductive: ( ) Dysmenorrhea ( ) Infection (Cervicitis) (vaginitis) ( ) Abortion (Spontaneous) (Threatened) ( ) Hyperemesis Gravidarium ( ) Uterine Tumors ( ) Cervical Polyp/Cancer ( ) Ovarian Cyst/Tumors ( ) Sexually-Transmitted diseases ( ) Hernia (Inguinal) (Femoral) ( ) Others Neuromuscular/Skeletal/ts: ( ) Peripheral Neuritis ( ) Torticollis ( ) Arthritis ( ) Others Lymphatics and Circulatory: ( ) Anemia ( ) Leukemia ( ) Cerebrovascular Accidents ( ) Lymphadenitis ___________ ( ) Lymphoma Infectious Diseases: ( ) Influenza ( ) Typhoid/paratyphoid fever ( ) Cholera ( ) Measles ( ) tetanus ( ) Malaria ( ) Schistosomiasis ( ) Herpes Zoster ( ) Chicken Pox ( ) German Measles ( ) Rabies ( ) Others Diseases due to Physical Environment: a) Diseases due to Noise and vibration ( ) Deafness (noise induced) ( ) White fingers disease ( ) Musculo-skeletal disturbances ( ) Fatigue

Male

Female

Total Number Of Cases

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b)

c)

d)

Diseases due to Temperature And Humidity abnormalities: Hot Temperature: ( ) heat strokes ( ) heat cramps ( ) dehydration ( ) heat exhaustion ( ) others Cold Temperature: ( ) Chilblain ( ) frost bite ( ) immersion foot ( ) general hypothemia ( ) others Diseases due to Pressure Abnormalities: ( ) Decompression Sickness: ( ) air emboism ( ) bends disease ( ) barotrauma ( ) hypoxia ( ) altitude sickness

Diseases due to radiation: ( ) cataracts ( ) keratitis ( ) burns ( ) radiation-related cancers TOTAL NUMBER

11. Report of Occupational Accidents/Injuries: Nature Contussion, bruises, hematoma Abrasions Cuts, lacerations, punctures Concussion Avulsion Amputation, loss of body parts Crushing Injuries Spinal injuries Cranial Injuries Sprains Dislocation/Fractures Burns 12.

Immunization Program (Indicate number immunized) Tetanus Toxoid Injection Tetanus Antitoxin Injection Tetanus Globulin Injection Hepatitis B Vaccine Rabies Vaccine Others (Please specify)

_______ _______ _______ _______ _______

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Male

Female

Total Number of Cases

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Male

Female

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Number of Cases ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________

Male

Female

Total

_______ _______ ___________ _______ _______ ___________ _______ _______ ___________ _______ _______ ___________ _______ _______ ___________ _______ _______ ___________

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 ormore) ( ( (

) ) )

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: (Please check) Kinds of Program

Seminar

Use of Visual Aid/Materials

Counselling

Nutrition Program Maternal and Child Care Program Family Planning Program Mental Health Activities Personal Health Maintenance Physical fitness Program: (Please check) Sports Activities Others (Please specify)

( (

) )

Yes Yes

( (

) )

No No

16. Hazards in the workplace: (Please check and give details of the substance)

a) Chemical Hazards: ( ) dust (Ex. Silica dust) ( ) liquids (Ex. Mercury) ( ) mist/fumes/vapors (Ex. Mist from paint spraying) ( ) gas (Ex. CO, H2S) ( ) others (please specify) (Ex. Solvents) b)

c)

Physical Hazards: ( ) noise ( ) temperature/humidity ( ) pressure ( ) illumination ( ) radiation/ultraviolet/ microwave ( ) vibration ( ) Others (Please specify) Biological Hazards: ( ) Viral ( ) Bacterial ( ) Fungal ( ) Parasitic ( ) Others

Substances and/or Sources

Number of workers exposed

________________ ________________

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________________ ________________

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________________

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d)

Ergonomic Stress: ( ) Exhausting physical work ( ) Prolonged standing ( ) Excessive mental effort ( ) Unfavorable work posture ( ) Static/monotonous work ( ) Others, specify

________________ ________________ ________________ ________________ ________________ ________________

________________ ________________ ________________ ________________ ________________ ________________

Submitted by: _______________________________ Medical Personnel/Title

___________________ Date Noted by: ______Anita F. Carbonel___________ Employer