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Date : Klinik Singapore Sungai Ara-Relau Agilent Technologies LDA 60 (4) 680 3888 (telephone) Malaysia Sdn. Bhd. (1075825-M), 60 (4) 680 3708 (fax) Bayan Lepas Free Industrial Zone, www.agilent.com 11900 Penang, Malaysia. Date : _________________ Klinik Singapore Sungai Ara-Relau Klinik Aman 823-G-03, Kejora Business Point 11 Jalan Sultan Azlan Shah Jalan Paya Terubong MK 13 11700 Penang 11900 Bayan Lepas, Penang (24 Hours) (9.00am to 1.00pm, 2.00pm to 10.00pm) Tel: 04 6581361 Tel: 04 6448488 Klinik Joe Fernandez (Tmn Jaya) Klinik Aman No. 30-1, Taman Jaya 603 Jalan Dato Kramat Jalan Kulim 10150 Penang 14000 Bukit Mertajam (Mon-Sun 9.00am to 9.00pm) (Mon-Fri 24 Hours) Tel: 04 2291844 (Sat, Sun, P. Holiday : 24 Hours) Tel: 04 5395217/04 5386439/04 5386448 Others, Non-Agilent Panel Clinic Klinik Singapore 71F Trengganu Road 10460 Penang (24 Hours) Tel: 04 2810114 Dear Doctor, Kindly conduct Physical Examination, Routine Urine Examination and Chest X-Ray on Mr./Miss/Madam : ___________________________________ I.C. No. : ___________________________________ and bill us accordingly. (Agilent Technologies panel clinic only) Yours Faithfully, Note to Clinic and Candidate: * Candidate to print all 5 pages of the form single sided * Clinic to detach and collect page 1 * Routine urine examination EXCLUDE urine cannabinoids or morphine * Expenses for other diagnostic tests not required in this pre-employment check-up _____________________________ will be borne by candidate HUMAN RESOURCE DEPARTMENT * Official receipt is required for reimbursement if payment is made by candidate * Candidate to submit claim at in-house clinic 1 PRE-EMPLOYEMENT HEALTH QUESTIONNAIRE (To be filled up by employee) Name : __________________________ Age : ______________ Date of Birth : ____________ I.C. No. : __________________________ Gender : ______________ Marital Status : ____________ Phone No. : __________________________ SOCSO No. : ______________ Employee No. : ____________ Job Title : __________________________ Department : ______________ Date of Hire : ____________ YES NO 1. Are you presently taking any prescribed medication? If "YES", explain: _________________________________________________________________________________________ 2. Have you been admitted to hospital before? If "YES", give reasons and dates: _________________________________________________________________________________________ 3. Have you undergone surgical operation previously? If "YES", give reasons and dates: _________________________________________________________________________________________ 4. Have you ever been discharged from another company for health reasons? If "YES", describe and give dates: _________________________________________________________________________________________ 5. Have you ever been injured in an automobile or motorcycle accident before? If "YES", describe and give dates: _________________________________________________________________________________________ 6. Is there any work that you cannot perform for any physical reasons? If "YES", explain: _________________________________________________________________________________________ 7. Have you ever had a job where you were exposed to excessive noise, dust, fumes or to other conditions which might have an effect on your health? If "YES", describe and give dates: _________________________________________________________________________________________ 8. Do you smoke? If "YES", how many cigarettes per day? _________________________________________________________________________________________ 9. Are you pregnant? IF "YES", how many months pregnant? (X-Ray is not recommended for pregnant women) _________________________________________________________________________________________ 10. Date of your last menstrual period : __________________ I understand that my employment is contingent upon the accuracy of the information given and it will be used as part of my Personal Record. I hereby certify that all information furnished on this form is true, complete and correct to the best of my knowledge. I understand that if any false statement is made, the Company reserves the right to terminate my employment instantly. I hereby acknowledge that my pre-existing medical condition will not be covered by Agilent Technologies Group Hospitalization & Surgical Plan for the first 12 months of my employment. Applicant's Signature Date 2 Name : ___________________________ PRE-EMPLOYMENT MEDICAL REPORT (To be filled up by doctor) Personal History : _________________________________________________________________________________________ Family History : _________________________________________________________________________________________ Drug History : _________________________________________________________________________________________ Any history of the following : YES NO YES NO 1. Hypertension 11.Gastric/Stomach Problems 2. Diabetes 12. Emotional Disorder/Hysteria 3. Heart Disease/Pacemaker 13. Hearing Problem 4. Leukemia/Thalassemia/ 14. Migraine/Frequent Headache Hemophilia 15. Dizziness/Fainting spells 5. SLE 16. Hernias 6. Kidney Problem 17. Allergies/Rashes 7. FITS/Epilepsy 18. Thyroid 8. Tuberculosis 19. Hepatitis 9. Asthma/Difficulty in Breathing 20. Any Physical Disabilities 10. AIDS Relevant/Medical History : _________________________________________________________________________________________ Remarks : _________________________________________________________________________________________ Occupational History : (Exposure to High Noise, Lead, Radiation, Dust etc) _________________________________________________________________________________________ Physical Examination Weight : _________________ Skin : _________________ Vision : Left Right Height : _________________ Eye : _________________ Distance _____ _____ Lung : _________________ Chest : _________________ Reading _____ _____ Heart : _________________ Back : _________________ Color _____ _____ CNS : _________________ ENT : _________________ Abdomen : _________________ Dental : _________________ Head/Neck : _________________ Joints : _________________ Limbs : _________________ 3 Name : ___________________________ Blood Pressure : _________________ General Condition : _________________ Pelvic Examination (Female) : _________________ Results of Investigation Done Urine Examination : ____________________________________________________________________ Chest X-Ray : ____________________________________________________________________ Suitable for scope work YES Comments : ___________________________________________ NO ___________________________________________ ___________________________________________ This is to certify that I have examined the above named and the following abnormalities/health concern were noted: FIT: UNFIT: Comments : _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Doctor's Signature : ______________________ Doctor's Name : ______________________ Date : ______________________ Clinic's Stamp 4 DEPENDANT'S OUTPATIENT REGISTRATION FORM (For permanent employee only) Name of Employee : __________________________________________________ Employee No. : ______________________ I.C. No. (Employee) : ______________________ Name of Spouse : __________________________________________________ Date of Birth (Spouse) : ______________________ Name of Children I.C. No. Date of Birth Gender 1. ________________________ _________________ ________________ ________ 2. ________________________ _________________ ________________ ________ 3. ________________________ _________________ ________________ ________ 4. ________________________ _________________ ________________ ________ 5. ________________________ _________________ ________________ ________ Note: Please complete a new form for any change or addition of dependants. 5.
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