PHM 2025 ENGLISH VERSION

  • Please fill out this form truthfully and completely.

  • GANDER*
  • Types of Examination
  • JENIS PEMERIKSAAN
  • DATE OF BIRTH*
     - -
  • TODAY
     - -
  • FUNCTION/ENTITY
  • FUNCTION/ENTITY
  • Contract Status
  • Contract Status
  • Work Location
  • Lokasi Kerja
  • Blood type*
  • STATUS*

  • NUMBER OF SON(S)     *  
    NUMBER OF DAUGHTHER(S) *   

  • NO HP :            *   
    NO OFFICE :                  Room ( for field ) :         

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  • WORKPLACE ACCIDENT HISTORY AND MAINTENANCE FROM HOSPITAL

  • In the past year, have you ever experienced Work accidents? ?*
  • Do you need to get hospital care     because of the accident? ?*
  • Whether there are functional disorders or disabilities after recover? ?*
  • In the past year, have you ever been treated in a hospital?*
  • Do you suffer from diseases that must be controlled continuously over the past year? ?*

  • SMOKING HABITS

  • Have you ever smoked ?*
  • Do you currently smoke ?*
  • Nikotin Level*
  • How often do you smoke deeply in cigarette smoke ?*
  • Do you smoke more in the first 2 hours at 1. Yes 2. No Morning ?*
  • Is it difficult not to smoke in a prohibited place smoke ?*
  • Do you keep smoking when you're sick ?*
  • In one day, which cigarettes are hard to miss ?*
  • Do you want to quit smoking ?*
  • If Yes, are you willing to join the Program ?*

  • ALCOHOL CONSUMPTION

  • Have you ever drunk alcohol ?*
  • Do you drink alcoholic beverages in 12 months last ?*
  • Do you drink alcoholic beverages in 4 weeks last ?*

  • COFFEE CONSUMPTION

  • Do you drink coffee?*
  • Do you drink coffee every day ?*

  • PHYSICAL ACTIVITY AND SPORTS

  • How intense is your workout ?*

  • FOODSTUFF CONSUMPTION PATTERNS

  • FAMILY HISTORY OF ILLNESS

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  • Among your Fathers/Mothers/Siblings, are you died from the above diseases at a young age From 45 years for men and 55 years for women ?*

  • FOR FEMALE EMPLOYEES

  • Are you currently pregnant ?*
  • When was the first day of your last period ?*
     - -
  • How much blood is there during your period ?*
  • Has your menstrual pattern been regular in the past year?*
  • Is there any pain related to menstruation ?*
  • Do you suffer from vaginal discharge frequently ?*

  • BIRTH CONTROL

  • Does your family follow Family Planning ?*
  • If YES, what method of birth control do you use ?

  • VACCINATION HISTORY

  • Have you ever been vaccinated against tetanus ?*
  • Have you ever been vaccinated against hepatitis ?*

  • BLOOD DONATION

  • Are you willing to donate blood when needed ?*
  • When was your last blood donation ?
     - -

  • Psychological Screening

    SELF REPORTING QUESTIONNAIRE (SRQ) 29

  • Instructions
    Read these instructions carefully before starting. The following questions relate to problems that
    may have bothered you in the past 30 days. If you believe you have experienced the issue
    mentioned in the question during the last 30 days, put a cross (X) in the Y column (meaning Yes). On
    the other hand, if you believe you have not experienced it in the last 30 days, put a cross (X) in the N
    column (meaning No). If you are unsure of your answer, choose the one that best fits between Y and
    N. We emphasize that your answers are confidential and will only be used to help address your
    concerns.

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