PDO Medical examinations specification SP1230

Petroleum Development Oman LLCRevision: 3.0Effective: 16 Apr 20079.20 Appendix T: Initial Medical Examination Report (EX3)EX3 MEDICAL – CONFIDENTIALPetroleum Development OmanMEDICAL DEPARTMENTCHILD HEALTH QUESTIONNAIREPLEASE COMPLETE YOUR CHILD‟S DETAILS IN BLACK-BLOCK CAPITALSEmployee‟s Name & InitialsPresent Area:Place of Examination Date Copied to: Next Area:Family Name Other Names Birth Date Nationality ReligionHeightcmWeightkgMaleFemaleHome/Leave AddressName and Address of Family DoctorTel No.Tel No.Has he/she had any of the following complaints?Please tick 'Yes' or 'No' column or put a '?' if uncertain; if 'Yes', please give details overleaf.NO YES NO YES1. Ear discharge/infection 11. Bronchitis or Asthma2. Sinus-or adenoid trouble 12. Highy fever or other allergy3. Recurrent throat infection 13. Skin trouble4. Eye problems 14. Kidney disease5. Convulsions or fits 15. Diabetes6. Frequent headaches or migraine 16. Serious accident/fracture7. Severe abdominal pain 17. Congenital abnormality8. Blood in stool (motions) 18. Any operation(s)9. Heart abnormality 19. Tropical disease10. Anaemia or other blood disorder 20. Any other health problem21. Is he/she under any treatment atthe present timeNOYES22. Has he/she been immunized against the following diseases: If “yes” give datesNOYES/DATE (lastdate only)i. Diphtheria vi. Measles Mumps Rubella (MMR)ii. Tetanusiii. Poliomyelitisiv. Whooping Cough (Pertussis)v. Haemophilus Influenzae B(HiB)vii. Tuberculosis (BCG)viii. Typhoidix. Yellow Feverx. OtherNOYES/DATEPage 82 SP-1230 : Specification for Medical Examination, Treatment & Facilities Printed 25-Sep-08The controlled version of this CMF Document resides online in Livelink®. Printed copies are UNCONTROLLED.