MEDEX 001

MEDEX 001

HEALTH DECLARATION AND CONSENT FORM
Full Name:*
IC No. or Passport No. :*
Company ID or Service No.:
Job Title*
Contact Number:*
Birth Date*

DayMonthYear
Date
Sex*
Home Address/Company Address:*
Place of Examination:*
Date of Examination:*

DayMonthYear
Date

Do you have or have you had: (Choose 'Yes' or No')*

Rows	Yes	No
Sinus Problem
Allergic rhinits/other Allergy
Any skin-problem
Any ear discharge
Neck/Gland Swelling
Dental Problem
Severe Headache/Migraine
Frequent Dizziness/Fainting Episodes
Stroke
Epilepsy
Lump in breast/armpit
Frequent lung infection
Shortness of breath
Coughed / Vomitted Blood
Bronchial Asthma/Bronchitis
Tuberclosis
Serious Chest Pain
Abnormal Heart Beat
Heart Disease
High Blood Pressure
Any Blood Disease
Severe Abdominal Pain
Gastritis/Ulcer
Recurrent Indigestion
Jaundice/Hepatitis/Liver Problem
Gall Bladder Disease
Marked Change in Weight
Kidney Stone/Disease
Painful Passage of Urine
Blood in Urine
Piles/Hernia
Blood in Stools
Varicose Veins
Serious Joints/Spinal Problem
Gout
Diabetes
Cancer
Surgical Operation
Mental Problem e.g. Depression
Drug and Alcohol Problem

Have you ever been?*

Rows	Yes	No
46. Exposed to Health Hazards such as Noise, Dust, Chemicals, Heavy Metals Reactions etc?
47. Suffered From Work Related Illness Before such as Asthma, Skin Condition, Hearing Loss, Backache, Blood disease etc?
48. Have you had any Previous Abnormal Audiometry/Lung Function Test/Chest X-ray?

Have you ever been?*

Rows Yes No

49. Have you had other illness(s)
Please state here*

Rows	Yes	No
Do you smoke/vape?
Do you take alcohol regularly?

Amount of alcohol per week?*
DiabetesHigh Blood PressureTuberculosisHeart DiseaseStrokeBlood DiseaseCancerBronhcial/AsthmaEczemaEpilepsy
Declaration & Consent Statement

I, the undersigned, declare and certify that the disclosure of the above information has been made voluntarily and that the information given above is ture and complete to the best of knowledge. I understand that false declaration of any information required above may result in disciplinary action/or legal proceedings being taken against me.

For Fitness to Work health assessment including pre-employment, I hereby give consent to the examining Medical Examiner to disclose the information given in this MEDEX forms and the result of my health assessment to the Company Health Advisors and/or authorized PETRONAS Personnel for the purposes of management of all matters related to PETRONAS employment proceses.

For Preventive Health assessment (Screening), I undestand that medical data will be analysed anonymously for the purpose of the PETRONAS health and wellness program implementation. My personal identity will not be revealed at any point of analysis nor willit be used for Fitness To Work or employment processes.

I undesrand that PETRONAS shall endeavour to implement the appropriate security safeguards and administrative procedures in accordance with the applicable local laws and regulations to prevent unauthorized or unlawful processing, usage and accidental loss or destruction of/or damage to, my Personal Data.

I have read, undestood and accept the contents of this Consent Statement given herein and I hereby give my consent for PETRONAS to manage my Personal Data in PETRONAS Occupational Health Database System.
Full Name*
Signature*

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Date:*

DayMonthYear
Date
Should be Empty:

Rows	Yes	No
50. Any gynaecological problem?
51. Are you pregnant?