Document EdJdg5g92MD3EG35om8BkvBmn
1WUTmte
W ^ e r D a t e of Birth
Race
Occupational Record
Past Medical Record Rheumatic Fever Chorea Scarlet Fever Other Conditions
Personal Record Diet Appetite
Family Record Father Mother Physical Exam ination Appearance Build Skin Lymph Nodes Mouth and Throat Teeth Ears Nose Eyes
U rine S.G. Sugar
Blood
Hemoglobin
Remarks
THE MEDICAL DEPARTMENT THE ASSOCIATED ETHYL COMPANY LIMITED
IN IT IA L BLENDER E X A M IN A T IO N FORM
. ' '-;
Marital State Children W eight (lb.) Height (ft. in.) Temperature Pulse Rate and Rhythm
Diphtheria Pneumonia Pleurisy
Bowels M ic tu ritio n
Brothers Sisters
C.V.S. R.S.
B.P.
A.S.
G.U.S.
C.N.S. Cranial Nerves :
Reflexes :
Motor System :
Sensory System :
1 G rip :
Albumen Microscopy
Notes overleaf
00102 26
Signature of Doctor
.
N29803
T O TH E CHIEF MEDICAL OFFICER
THE ASSOCIATED ETHYL COMP
LIMITED
lv
W * - *7 : v ,
nr4f^ $.
0010227
' ^ Signature o f D octor
/
THE ASSOCIATED ETHYL COMPANY LIMITED
Ui
MEDICAL SERVICES OVERSEAS
GENERAL REPORT
BLENDING OPERATORS
WpitfG PLANT (Name and Location).
STATE OF HYGIENE {Plant and Equipment).
:
"t
EMPLOYEE {Name).
MEDICAL {Initial or Routine).
- . -
REPORT {Fit or Unfit).
DATE
REMARKS
.:
;
v
'
- .
r;
:.
. -.
.: v
.
- ;. ' . > '. _
' ,.
-V
- : 'V '- ::'. ;
V.
f
'
* . ' . : * - * *
F . K f - '
iM '
" ' * - f * . -
' -'
" -: J ; :`- V
''
~.. ^ . :
' "
:'
`-Vt - ii..--
- '
.;
*. -
..
v '
'" .
THE ASSOCIATED ETHYL COMPANY LIMITED
ROUTINE BLENDER E X A M IN A T IO N FORM
.s
AyHwF " Wpste
-----------------------
1------------
i
;
LOCATION
Pallor '
Weakness
i :i [
Fatigue Sleep Disturbance Insomnia Anorexia indigestion
. | ! j I
1 i ;i H
i
j
i !j .
1
j
Constipation
|' i
W eight
i
Anxious Expression ;
1
ii .... ... L _____
Metallic Taste
,
Headache
:
Sensory Disturbance j
Dysuria
Temperature Pulse
: j
j
Blood Pressure Tremor Grip (Rt.)
j
i
i>
Grip (Lt.) Teeth Gums
j
j j j j
Urine Ph.
Urine Albumin
!
Urine mg./L. (Pb.) ;
Urine Sugar
Haemoglobin
Canisters last changed
No. of blends since last examination
\
'
1 :
1
i 1
i
i i i
Masks
' ili!!
------------------------------------------------------------------- ;------------------------ --------------------------------------------------i______________ 1______________ __________
Gloves
!.
i
;
.Clothes
: 1
___ L;
! '!
i'
!
i
EMPLOYER
r .i
-- -
!!
1i ______________ 1______________ i
i i it i ii
i!
i............ 1
i
1
.
1
ji
--
-- --
1 ij .
!
1'
i
I
fO THE CHIEF MEDICAL OFFICER ASSOCIATED ETHYL COMPANY LIMITED
HYL BLENDERS AND EQUIPMENT REPORT
^ ..' .......... .
...... --
LOCATION
TN D S SINCE LAST EXAMINATION :
y Report
Equipment Report
5VMPTOMS :
Cardiac...... Respiratory Alimentary............ Genito - Urinary... Central Nervous--
c p c p l AT
QUESTIONS :
Sleep...... Appetite Weight... Bowels...
SIGNS :
Heart : Size :................. BP. : Systolic.............. C.N.S. : Reflexes.............. M outh: (Teeth)............... Urine : Albumin
Rate and Rythm. Diastolic........... . Tremors............. (Gums)................ Sugar__
Cannisters Last Changed: Masks : * In Good Condition/Require Renewing Gloves : * In Good Condition/Require Renewing Clothes : * In Good Condition/Require Renewing Other Equipment:
* Delete as Necessary
Special Examinations (When Intoxication is Suspected).
Remarks
Hmoglobin______ _ Lead in Blood______ _______________ ___ mg./100 Gm. Lead in Urine............................................................ mg./Litre
REPORT : This Man is Fit and Well, or : .........................................................................................................................................
Date................... .................:... 0010230
Doctor...................