Health Fitness Certificate
for the purposes of permission to work in Confined Space
Named of Person examined …………………………………………………………….……………
NRIC/Passport No. …………………...………………… Date of Birth …….…………………
Name and addressed of Employer:
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
I hereby certify that I have examined the above named person on …..…………………………
From the information related to health being declared by the person, my clinical examination
and diagnostic tests recorded on medical examination form, I certify that this worker is :
FIT
NOT FIT
for working in confined space.
Doctor's signature : …….……………………………
Name of OHD : …….……………………………
Date : …….……………….…
DOSH RN : …….……………………………
Name of clinic : …….……………………………
…….……………………………
Tel and Fax no : …….……………………………
MEDICAL EXAMINATION CHECKLIST FOR WORKING IN CONFINED SPACE
(TO BE FILLED UP BY OCCUPATIONAL HEALTH DOCTOR)
This is to certify that the below statements are true. I give consent to the OHD for medical
examination and to communicate with the management regarding my work capability after
discussion with me.
Worker's signature : ………………………………………. Date : ………………………
A) Worker
Name : ……………………………………………………………………………………
Address : ……………………………………………………………………………………
……………………………………………………………………………………
Postcode : …………………… District : …………………… State : ………………….
Tel. No. : ……………………..……
IC No. : ………………………..…
Age : ……….… years Sex : Male Female
Ethnic : Malay Marital status : Single Married
Chinese
Indian
Others
Nationality : Malaysian citizen Non citizen (specify) :
….……………………………………………
B) Next of kin to be contacted in case of emergency
Name : ……………………………………………………………………….……………
Relationship : ………………………………………………………………………….…………
Address : …………………………………………………………………………………….
…………………………………………………………………………………….
Tel. No. : ……………………………………………….
C) Employer
Name : ………………………………………………………………………………..……..
Address : ……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….
Tel. No. : …………………………….. Fax No/E-mail : ……………………………...
D) Occupational History
1. Job title : ………………………………………………………………………………………
2. Duration of service : ……………………………………………………………………..…
3. Any training received for this job? Yes No
4. Other job ( other than this job ) : ……………………………………………………………
5. H/O using any PPE Yes No
Specify : ……………………………………………………………………………………
6. H/O allergy or difficulty in using PPE Yes No
Specify : ……………………………………………………………………………………
E) Do you have any history of or suffering from thefollowing conditions ?
1. Smoking
a) Smoker No of years smoked : years
b) Non smoker No of cigarette/day :
c) Stopped smoking
2. Medical condition Yes No Remarks
a. Eye problems ( including visual acuity,
or night blindness )
b. Ear problems ( including hearing,
inner ear disease or recurrent vertigo )
c. Nose (trouble smelling odours )
d. Central Nervous System :
i) Epilepsy, fits or convulsion of any kind
ii) Stroke with residual abnormality
iii) Disease affecting co-ordination e. g.
Parkinson
iv) Serious head injury
v) Severe headache, giddiness or migraine
e. Cardiovascular System
i) Uncontrolled hypertension
ii) Heart disease ( include IHD, Heart failure)
or Arrythmia
iii) Congential heart disease with cardiomegaly,
ECG abnormality or inadequate oxygenation
f. Respiratory System
i) Uncontrolled asthma
ii) COAD
iii) Acute pulmonary infection ( including T B)
Yes No Remarks
g. Gastroitestinal System
i) Peptic ulcer disease
h. Endocrine System
i) Uncontrolled diabetes mellitus
i. Renal System
i) Chronic renal disease e. g. nephritis
ii) Renal failure
j. Musculoskeletal System
i) Deformity, disability or amputation of
the body/limbs
ii) Chronic or recurrent disease of muscle,
bone or joint
k. Dermatological System
i) Acute or chronic inflammatory skin condition
l. Psychiatric
i) Mental illness ( include
depression, psychosis, mania or anxiety )
ii) Drug and alcohol dependent
( current or past )
iii) Claustrophobia
(fear of enclosed spaces)
m. H/O taking any medications
i) Cough/cold medication
ii) Transquilisers
iii) Hypnotics
iv) Other drugs ( incuding cytotoxic agents,
anti-coagulants or immunodepressansts )
n. Any other health problem or injury
F) Family history
Yes No Specify ( if yes )
1. H/O medical illness :
2. H/O allergy :
3. Other illness ( specify) :
G) For female only :
Currently Pregnant No Yes
H) Pemeriksaan Fizikal
1. Anthropometry
a) Weight : ……………………………… kg
b) Height : ……………………………… cm
c) BMI : ………………………………
2. Vital sign :
a) Blood pressure …………………mmHg b) Pulse rate ……………….. per minute
3. General condition :
a) Eye Right Left b) Ear Right Left
i) Visual acuity i) External ear
ii) Visual field ii)Tympanic membrane
iii) Colour vision iii) Air conduction
iv) Fundoscopy iv) Bone conduction
Right Left
c) Nose d) Throat ……………………………
e) Skin …………………… f) Lymph nodes ……………………………
4. Target organ :
Normal Abnormal Other ( if abnormal )
a) Central Nervous System
b) Cardiovascular System
c) Respiratory System
d) Gastrointestinal System
e) Endocrine System
f) Renal System
g) Musculoskeletal System
I) Investigations
Date Normal Abnormal Remarks
1. FBC
2. UFEME
3. Spirometry
FVC
FEV 1
FEVI 1/FVC
4. Other ( specify )
On the basis of the applicant’s personal declaration, my clinical examination and diagnostic test
results recorded on the medical examination form, I declare that this worker is FIT / NOT FIT for
working in confined space.
Doctor’s
: DOSH RN :
signature …………………………………… ……………………..
Name of OHD : Clinic tel no :
…………………………………… ……………………..
Name of clinic : E-mail add :
…………………………………… ………………………..
Fax no :
…………………………………… ………………………..
Date :
……………………………………
