PDO Medical examinations specification SP1230

Petroleum Development Oman LLCRevision: 3.0Effective: 16 Apr 20079.21 Appendix U: Initial Medical Examination Report (EX4)EX3 MEDICAL – CONFIDENTIALPetroleum Development OmanMEDICAL DEPARTMENTCompany Number:Employee‟s Name & InitialsQUESTIONNAIRE FOR TRANSFEREES OVER 12 YEARSWITHIN WESTERN EUROPE OR RETURNING TO BASECOUNTRYPLEASE COMPLETE YOUR CHILD‟S DETAILS IN BLACK-BLOCK CAPITALSPresent Area:Next Area:Family Name Other Names Birth Date NationalityMale Employee Spouse Date and place of last Shell Medical ExamFemale Son DaughterFiancaè/eHome/Leave AddressName and Address of Family DoctorTel No.Tel No.Please tick "Yes" or "No" column, as appropriate. If Yes, please specify below by referring to the correspondingnumberNOYES1) Do you feel unfit?2) Have you, since your last medical examination, been treated by your family doctor or aspecialist? If so, for what reason, and state the name of the hospital in the event ofhospitalisation/operation3) Have you, in the recent past, taken medicines regularly, or are you still doing so?4) Do you have any allergies (food, medicines)?5) Do you have any medical problem related to travel?6) Do you smoke?If so, what and how much/day?cigarettes / cigars / pipe7) Do you drink?If so, what is your average alcohol intake per day? .8) What is your present weight undressed? kg9) With regard to your present state of health, would you like to have a medical examination or seea Company doctor?Details:Statement: I have read the above questions.The answers are correct and no information concerning my present or past state of health has beenwithheldSigned: .............................................................................. Date: ..................................................FOR COMPLETION BY COMPANY DOCTORPage 84 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.