Medical Practitioner's Report - Jabatan Laut Malaysia
Medical Practitioner's Report - Jabatan Laut Malaysia
Medical Practitioner's Report - Jabatan Laut Malaysia
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JL/HEPP/D/16JABATAN LAUT MALAYSIAIbu Pejabat <strong>Laut</strong> Semenanjung <strong>Malaysia</strong>, Peti Surat 12, 42007 Pelabuhan Klang Tel: 03-3695100, Fax: 03-3685289,E-mail: kpgr@marine.gov.my http://www.marine.gov.myMEDICAL PRACTITIONER’S REPORTI have examined______________________________________ IC/Passport No: __________________as per the <strong>Malaysia</strong>n Marine Department medical standards JL/P/02/98 and the results are as follows:Height/Weight _______ metres _______ kg EXAMINATION RESULTSHearing _______ _______right left FITEyesight______________right left UNFITEyesight with visual aids _______ _______rightleftColour VisionTEMPORARILY UNFITUrinalysis ______ gula _______ albuminPulse_______ /minBlood pressure__________Chest X-rayNormal/AbnormalX-ray Nuumber. : _________________ECGNormal/AbnormalNormal Abnormall Remarks1. Infectious diseases _________________2. Malignant Neoplasm _________________3. Endocrine and Metabolic Disease _________________4. Disease of the blood andblood forming organs_________________5. Mental Disorders _________________6. Central Nervous system _________________7. Cardiovascular system _________________8. Respiratory system _________________9. Digestive system _________________10. Genito‐Urinary System _________________11. Pregnancy No Yes (week ________) ____________12. Skin _________________
13. Musculo‐skeletal system _________________14. Speech Defects _________________15. Ears/Nose/Throat _________________16. Eyes _________________This certificate is valid until _____________________________________________________________DateSignature of <strong>Medical</strong> PractitionerMMC No:
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