KUSUMA MEDICAL CENTER ENGLISH

  • Fill out this form real and complete.

  • GENDER*
  • Date of Birth*
     - -
  • TODAY
     - -
  • STATUS*

  •       Number of Children Son *                     

  •       Nmber of Children Daughter *            

  • TELEPHONE NUMBER :            *   
    TELEPHONE OFFICE NUMBER:            EKSTENSION :         

  • ARE YOU PROSPECTIVE EMPLOYEE*
  • Rows
  • Rows
  • Rows

  • WORK ACCIDENTS AND HOSPITALIZED HISTORY

  • In the past year have you ever had an accident due to work ?*
  • Did you need to hospitalized because of the accident?*
  • Were there any impaired function or disability after recovery ?*
  • In the past year have you been hospitalized ?*
  • Do you suffer from a disease that must be controlled continuously during the past year?*

  • SMOKING HABITS

  • Haved you ever smoked?*
  • Do you still smoke until today?*
  • Nikotin levels*
  • How often do you deeply inhale the smoke?*
  • Do you smoke more within the first 2 hours in the morning ?*
  • Do you find the difficulty not to smoke in places that banned smoking ?*
  • Do you continue to smoke when you’re sick?*
  • In one day, what cigarettes are difficult to pass?*

  • ALCOHOL CONSUMPTION AND NARCOTICS

  • Do you ever drink alcohol?*
  • Do you drink alcoholic beverages in the last 12 months?*
  • Do you drink alcoholic beverages in the last 1 month ?*
  • Have you ever used drugs?*

  • PHYSICAL ACTIVITY AND SPORTS

  • How does the intensity of the exercise?*

  • FOOD CONSUMPTION PATTERNS

  • FAMILY HISTORY OF DISEASE

  • Rows
  • Rows
  • Among of your father / mother / siblings, was anyone died 1. Yes 2. No because of the diseases above, less than 45 years for men and 55 years for women ?*

  • FOR WOMEN EMPLOYEE

  • Are you currently pregnant ?*
  • When was the first day of your last period ? *
     - -
  • How much blood when you menstruate ?*
  • Do you have a regular menstrual pattern in the past year?*
  • Are there any pain associated with menstruation ?*
  • Do you often experience white discharde (flour albus) ?*

  • FAMILY PLANNING

  • Does your family follow the family planning?*
  • what method of birth control or contraception do you use ?

  • HISTORY OF VACCINATION

  • Have you been vaccinated against tetanus?*
  • Do you ever get vaccinated for hepatitis ?*

  • BLOOD DONORS

  • Are you willing to donate blood ehen needed ?*
  • When did you do the 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.

  • Rows
  •  
  • Should be Empty: