Occupational Medical Certificate
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ScribdTranslationsOccupational Medical Certificate
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ScribdTranslationsWORKPLACE HEALTH MEDICAL EXAMINATION
To comply with article 22 of the Occupational Risk Prevention Law 31/1995 of November 8, the worker,
whose data and signature are in this document, gives his consent to undergo medical tests and
necessary complements to assess their job fitness according to the risks in their work position, and that the content
and the results of the same should be available to the healthcare personnel in charge of Health Surveillance at your company.
The content of medical exams and other statements related to your health will be considered confidential.
subjects who consult them on the duty of professional secrecy.
You are informed that the occupational health medical exam includes an anamnesis (questionnaire and/or medical interview).
clinical exploration, biological control (analysis) and complementary studies based on the inherent risks of your position
work, as well as a detailed description of your work history. We appreciate it if you fill out this questionnaire.
WRITING IN CAPITAL LETTERS AND MARKING WITH AN X WHERE APPLICABLE.
AFFILIATION DATA
LAST NAMES NAME
NATIONALITY ID card S.S. No. SEX
DATE OF BIRTH / / MARITAL STATUS NUMBER OF CHILDREN
ADDRESS
LOCALITY CP PHONE
LABOR DATA
COMPANY Date of Registration
WORK CENTER
JOB POSITION Date of discharge
TASK DESCRIPTION
Occupational Risks
PROTECTION MEASURES
EXTRACURRICULAR TASKS WITH THE SAME RISKS
TRABAJOS ANTERIORES (puestos de trabajo/riesgos/tiempo)
* IMPORTANT NOTE: FOR THE VALIDITY OF THIS Applicant's Signature:
DOCUMENTS MUST BE SIGNED ON ALL PAGES
In compliance with the provisions of Organic Law 15/1999 on the Protection of Personal Data, we inform you that your data is in a file owned by the Company.
of Prevention of Mutua Balear PREVIS, S.L.U., duly registered with the Data Protection Agency, where you can exercise your rights of access at any time,
rectification and cancellation of your data, through timely communication to the holder Society of Prevention of Mutual Balear PREVIS, S.L.U., C/ Antich, No. 8 ground floor, 07013 Palma de Mallorca
[Link] | Tel. 971 715 207 1/5
PERSONAL MEDICAL HISTORY
Suffers or has suffered:
CONGENITAL DISEASE
HEREDITARY
NO YES
CONGENITAL DEFORMITY
NO YES
CHILDHOOD DISEASES Meningitis
IMPORTANT NO YES Epilepsy
Others
ALLERGIES
NO YES
EYE DISEASES Myopia Waterfalls
Do you wear glasses? NO YES Hyperopia Plebiscite
Astigmatism Surgery for...
Do you use hearing aids?
EAR DISEASES
Are you listening well? NO YES YES NO
DENTAL DISEASES Caries
NO YES Gingivitis
Others
Thyroid diseases Hypothyroidism
NO YES Hyperthyroidism
Others
DISEASE OF THE Tuberculosis Asma
LUNGS NO YES Pneumonia Pneumothorax
Bronchitis Others
HEART DISEASES Arrhythmia Blow
NO YES Valvulopathy Others
Coronary disease (Myocardial infarction)
TENSION ALTERATION Low blood pressure, hypotension
NO YES
ARTERIAL High blood pressure, hypertension
DIGESTIVE DISEASES Gastritis Constipation
NO YES Ulcer Blood in stool
Diarrheas Others
Liver diseases
NO YES Hepatitis
Others
DIABETES / SUGAR Control with diet Sugar drops
NO YES Oral antidiabetics Others
Insulin
METABOLIC ALTERATIONS Elevation of cholesterol
NO YES Triglycerides
Uric Acid
* IMPORTANT NOTE: FOR THIS DOCUMENT TO BE VALID, ALL PAGES MUST BE SIGNED Applicant's Signature: 2/5
[Link] | Tel. 971 715 207
KIDNEY DISEASES Urinary infections Prostate problems
UROLOGICAL NO YES Renal colic Others
Urinate blood
DISEASES NO YES Headaches Coma
NEUROLOGICAL Tremors, convulsions Vertigo
Epilepsy Paralysis
Loss of consciousness
Others
PSYCHIATRIC DISEASES Anxiety Psychosis
NO YES Depression Others
Phobias
PROBLEMS Arthritis Lumbago
OSTEOMUSCULAR NO YES Osteoarthritis Dislocation
Rheumatic diseases Tendinitis
Bone fractures Amputation
Carpal tunnel syndrome
Others
SKIN DISEASES
NO YES
Infectious diseases Meningitis Malaria
IMPORTANT NO YES Hepatitis A Tuberculosis
Hepatitis B HIV - AIDS
Hepatitis C
Others
HOSPITAL ADMISSION
NO SI
SURGERY OPERATIONS Tonsils
NO YES Appendicitis
Others
SERIOUS ACCIDENTS
NO YES
AFTERMATH
NO YES
Does she/he suffer from illness? Diabetes
CHRONICLE? NO YES Hypertension
Others
Do you have varicose veins? Capillary dilations
NO YES Varices
* IMPORTANT NOTE: FOR THIS DOCUMENT TO BE VALID, ALL PAGES MUST BE SIGNED Applicant's Signature: 3/5
[Link] | Tel. 971 715 207
HABITS
TOBACCO
Never | Exfumador desde ........ años | Habitual desde hace ........ años | Cantidad al día ........
ALCOHOL
Never Sporadic | Fines de semana ........ copas | Habitual ........ al día
CAFES / TE
Never Sporadic Habitual ........ per day
DRUGS
Never Sporadic Weekends Habitual Type of drug Ex-consumer for ...... years
SPORT
Never Sporadic Habitual
MEDICATIONS
sporadically Last two weeks Currently takes (Which?)
HOURS OF SLEEP
....... hours a day
HOUSEHOLD CHORES
If No
FAMILY MEDICAL HISTORY
Father's diseases:
Deceased from:
Mother's diseases:
Deceased of:
Other relatives (relationship):
Diseases:
He has diseases:
CONGENITAL / HEREDITARY DISEASES IN YOUR FAMILY
Diabetes | Hipertensión arterial | Del corazón | Colesterol | Others
Only respond if you are a woman
Gynecological problems?
Yes No Menstrual disorders Infections Losses | Others
Breast problems
Yes No Lumps, nodules Secretion | Others
Gynecological examinations
Si No | Fecha de la última/ revisión /
Do you take contraceptives?
Yes No | Which one?
Date of the last period
Si No | Fecha / /
Are you pregnant?
Si No | Fecha probable del / parto /
Currently suffering from:
It is currently:
High Sick leave due to common illness Sick leave due to workplace accident Sick leave due to occupational illness Invalidity
* IMPORTANT NOTICE: FOR THIS DOCUMENT TO BE VALID, ALL PAGES MUST BE SIGNED Applicant's Signature: 4/5
[Link] | Tel. 971 715 207
SURNAMES NAME ID
You grant consent to the medical area of the Prevention Service of your company for the purposes of what is requested from you.
health centers where medical assistance has been received, and whose data will be provided by the undersigned, the information
doctor who works in them in order to assess their health status, this document serving for the purposes of
to believe the expressed authorization.
And declares that he has answered the questions honestly and has not concealed any illness or mental defect.
a physicist who would have suffered or is suffering currently
FILL IN AT THE END OF THE MEDICAL EXAM
I have received information about my health regarding the risks of my job provided by the healthcare staff.
of the Prevention Service that attended to me during the occupational health medical examination, as well as regarding the content
of the results, which are currently available, of the additional tests and examinations carried out
due to said health exam; and they have responded and clarified my doubts regarding it.
In........................................................... a............ of ...................... of ...............
Company: ______________________________
And I have been given the results of the occupational health exam.
On........................................................... at............ of ....................... in ...............
Firma: ______________________________
The Prevention Society of Balearic Mutual PREVIS, S.L.U wants to thank you for the trust placed in us.
We hope that the service received is to your liking.
* IMPORTANT NOTE: FOR THIS DOCUMENT TO BE VALID, ALL PAGES MUST BE SIGNED Applicant's Signature: 5/5
[Link] | Tel. 971 715 207
