Republic of the Philippines
Department of Labor and Employment
National Capital Region
ANNUAL MEDICAL REPORT FORM
2022
2022 to December 31, _____
For Period January 1, _____
1. Name of Establishment:__________________________________________________
2AJ ENGINEERING SUPPLY & SERVICES
CONTRACTOR
F. MEDRANO COR. PUROK-7 BRGY. BAGONG POOK LIPA
2. Address:______________________________________________________________
BATANGAS
LARRY B. SEBASTIAN
3. Name of Owner/ Manager:________________________________________________
4. Nature of Business & Product/ Service (Ex. Manufacturing – textile)_______________
CONTRACTOR
________________________________________________________________________
28
5. Total Number of Employee:_________ REGULAR WORKING HOUR
Number of Shift:________________________
6. Number Distribution of Employee as to nature/workplace, sex & workship:
office Product/Shop
1st Shift 2nd Shift 3rd Shift
3
Male :___________ ___________
25 ______________ ____________
2
Female:__________ ___________
0 ______________ ____________
Total:___________
5 25
___________ ______________ ____________
7. 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
1
c. The employer engages the services of :
( ) Occupational health practitioner
Name: ______________________________________________________
ROMULO ANASCO SO3
F. MEDRANO COR. PUROK-7 BGY. BAGONG POOK LIPA
Address: ____________________________________________________
BATANGAS
( ) 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: _________________________________________________
__________________________________________________
8. Emergency Occupational Health Services:
a. The employer provides a treatment room/medical clinic in the work place with
medicines and facilities
( ) Yes _________________
OFFICE ( ) 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
2
d. The following occupational health personal of this establishment have under
gone training in occupation health and safety/first aid :
( ) Occupational health physician
( ) Occupation health dentist
( ) Occupation health nurse
( ) first - aider
( ) Others, please specify___________________________________________
____________________________________________________________
9. Occupational Health Services
a. The occupational health personnel of this establishment regular appraisal of the
sanitation system in the workplace:
( ) Yes ( ) No
b. Number of workers who underwent the following medical examinations:
Physical Exam X-rays Urinalysis
1. Pre-placement ____________ ________ ___________
2. Periodic ____________ ________ ____________
3. Return-to –work ____________ ________ ____________
4. Transfer ____________ ________ ____________
5. Special ____________ ________ ____________
6. Separation ____________ ________ ____________
Stool Blood ECG Others
Exam Test
1. Pre-placement ______ ______ ______ ______
2. Periodic ______ ______ ______ ______
3. Return-to-work ______ ______ ______ ______
4. Transfer ______ ______ ______ ______
5. Special ______ ______ ______ ______
6. Separation ______ ______ ______ ______
-3-
10. 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 ______
1 _______ __________
1
( ) Others ______ _______ __________
Mouth & ENT:
( ) Gingivitis ______ _______ __________
( ) Herpes Labiales/
nasalis ______ _______ __________
( ) Otitis Media
Externa ______ _______ __________
( ) Deafness ______ _______ __________
( ) Meniere”s Syndrome
/Vertigo ______ _______ __________
( ) Rhinitis/Colds ______ _______ __________
( ) Nasal Polyps ______ _______ __________
( ) Sinusitis ______ _______ __________
( ) Tonsilio
4
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 ______ _______ __________
5
( ) Liver Cirrhosis ______ _______ __________
( ) Hepatic Abscess ______ _______ __________
( ) Cancer (Hepatic/
Gastric) ______ _______ __________
( ) Ulcer ______ _______ __________
( ) Others ______ _______ __________
Genito Urinary:
( ) Urinary Tract
infection 2
______ _______ __________
2
( ) Stones ______ _______ __________
( ) Cancer _____ _______ __________
( ) Others _____ _______ __________
Reproductive:
( ) Dysmenorrhea _____ _______ __________
( ) Isfection
(Cervicitive)
(Vaginitis) _____ _______ __________
( ) Abortion
(Spontaneus) _____ _______ __________
(threatened) _____ _______ __________
( ) Hyperremesis
Gravidarum _____ _______ __________
( ) Uterine Tumors _____ _______ __________
( ) Cervical Polyp/
Cancer ______ _______ _________
12. Immunization Program (Indicate number immunized)
Nature Male Female Total No.
Of Cases
Tetanus Toxoid Injection ______ ________ ___________
Tetanus Antioxin Injection ______ ________ ___________
Tetanus Globulin Injection ______ ________ ___________
Hepatitis B Vaccine ______ ________ ___________
Rabies Vaccine ______ ________ ___________
Others (Please Specify) ______
2 ________
28 ___________
30
COVID-19 VACCINE
6
13. Keeping of Medical Records of Workers (Please Check)
( ) Done ( ) Not Done
14. 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.
15. 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
16. 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) _____________
GRINDING 8
________________
( ) Liquid (Ex. Mercury) _____________ ________________
( ) Mist/fumes/vapors
(Ex. mist from paint spraying) _____________
WELDING ________________
8
( ) Gas (Ex. CO, H2S) _____________ ________________
( ) Others (please specify)
(Ex. solvents) _____________ ________________
7
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 _____________
HAULING 6
_________________
( ) Prolonged standing _____________ __________________
( ) Low back pain _____________ __________________
( ) Unfavorable work posture _____________ __________________
( ) Static/monotonous work _____________ __________________
( ) Others, specify _____________ __________________
Submitted by:
__________________________ __________________
Medical Personnel/Title Date
Noted by:
LAARY B. SEBASTIAN
_______________________________
Employer
