Occupational Health Doctor Clerking System
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Employee Personal History
Employee's Name:
Please enter the employee's name
I/C No.:
Please enter the IC number
Age:
Please enter a valid age
Employee ID:
Please enter the employee ID
Role:
Please enter the employee's role
Date:
Please select a date
Time:
Please select a time
Gender:
Male
Female
Superior:
Please enter the superior's name
Superior Post:
Please enter the superior's post
Company:
Please enter the company name
Indication for referral:
Please enter the referral reason
Diagnosis:
Please enter the diagnosis
Current Condition:
a. Clinical Status:
Employee is currently working. Employee was previously on medical leave from first date until last date from hospital name.
Please enter the clinical status
b. Occupational Status:
Employee has been working with company name since first date. First employment as first job and current employment as current job. Working schedule: working schedule.
Please enter the occupational status
c. SOCSO / Financial Aid Status:
Have not receive any benefit.
Please enter the SOCSO status
Next: Clinical History
Clinical History
a. History of Presenting Illness:
Employee presented with complain on date. Referred by clinic name to Hospital name. Diagnosed as diagnosis. Proceed with treatment on treatment date. Post treatment, employee condition after treatment. Discharged discharge date and planned for plan.
Please enter the history of presenting illness
b. Past Medical History / Past Surgical History / Allergy History:
c. Physical Examination:
Patient walking upright. GCS gcs. BP BP HR HR. Able to converse fluently and well. PHQ9 score score (low). Able to complete mini mental state examination well. Lungs clear. CVS S1S2 PA Soft.
Please enter the physical examination details
d. ADL:
ADL independent. Lying, bathing, clothing, eating unaided. Sitting < 2 hours. Sit to stand unaided, standing < 2 hours, walking unaided. Able to do house chores with limitation on carrying weight. Average pain score at rest 0/10, pain on movement 4/10. On C. Celebrex PRN for pain management.
Please enter the ADL details
e. Mental Health:
Patient euthymic, optimistic about health outcome, good eye contact, responding to questions. PHQ9 score low. Optimistic about work outcome.
Please enter the mental health assessment
f. Social History:
Right handed. Stay in place (30 minutes to work), with number child and any. Come to work by transport. Good family support. Clinic follow-up assisted by who. Smoker, non-alcohol drinker, no drug history. Education level level.
Please enter the social history
g. Maximum Medical Improvement (MMI) Assessment:
Employee has not reached maximum medical improvement and is on active treatment.
Please enter the MMI assessment
Previous
Next: Work History
Work History
a. Work history by HR:
as attached
Please enter the work history
b. Work schedule:
8am - 5pm Monday to Friday, off Saturday Sunday
Please enter the work schedule
c. Work Task narrated by employee:
On 01 January 2026, based on employee's work description
Please enter the work tasks
d. Discussion with supervisor:
On 01 January 2026, supervisor has conveyed
Please enter the supervisor discussion
e. Doctor feedback:
Doctor's assessment of employee's work capacity and limitations
Please enter the doctor's feedback
f. Job description analysis:
The employee job description is of low strain task which is unsuitable for his condition.
Please enter the job description analysis
Previous
Next: Appendix
Appendix - Supporting Documents
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Next: Summary
Summary
Employee Name:
I/C Number:
Reference Number:
Summary:
Employee presented with diagnosis. He has received optimal treatment with treatment. Consequently, MMI assessment The current employee job description is appropriate to employee current condition. As such, we recommend:
Please enter the summary
Plan:
- To continue Pantai Hospital Penang follow up and medication advice. - TCA OHD date -
Please enter the plan
References:
Nil
Previous
Next: Settings
Settings
Doctor's Name:
Please enter the doctor's name
Doctor's Qualification:
Please enter the doctor's qualifications
MMC Number:
Please enter the MMC number
OHD Number:
Please enter the OHD number
Clinic Name:
Please enter the clinic name
Clinic Address:
4703, Jalan Bagan Luar, Kampung Benggali, 12000 Butterworth, Pulau Pinang
Please enter the clinic address
Clinic Phone Number:
Please enter the clinic phone number
Clinic Email Address:
Please enter a valid email address
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