Form No.9 (Related to Article 57) (1) Report of medical examination of a person for whom a Personal Health Record has been issued (Benzidine, etc.) Date of birth: Cystoscopic test Normal Hyperemia, anemia, swelling, scar, ulcer, polyp, tumor Observation: bleeding, : Bloody urine (hematuria), frequent urination (pollakiuria), painful urination, difficulty in urination Pyelography Normal Abnormal Observation: Bloody urine (hematuria), frequent urination (pollakiuria), painful urination, difficulty in urination Microscopic examination of urinary sediment No cells detected Red blood cells, white blood cells, epidermal cells Cytologic test (Papanicolaou's test) Negative, suspicious, positive
Form No.9 (Related to Article 57) (2) Report of medical examination of a person for whom a Personal Health Record has been issued (pneumoconiosis) Pneumoconiosis control Pulmonary function test classification: 1. Height m Age Date of birth: Age ( ) Male / Female 2. Estimated lung capacity l Radiography test Examination date: Subjective symptoms Image 45 1.Photography date: 2. Film number: 3. Radiographic conditions: Intensifying screen Clinical chest examination Dyspnea Cough Phlegm Palpitation Others I, II, III, IV, V Opinion of physician: Opacity Category Granular opacity / Irregular opacity b. Classification of large opacity (A B C) KV c. Other observations mas 4. Radiographic appearance a. Clasiffication of small Image 46 Objective symptoms / Cyanosis Clubbed finger Adventitious sounds Others Type pqr (Pl/ l / /b / / / / / / b) (site: ) Primary examination Secondary examination Oxygen partial pressure Torr Torr Carbon dioxide partial pressure Torr Torr Alveolar-arterial oxygen difference. Torr. Torr Evaluation: F (Image 47) Subjective symptoms Close examination for tuberculosis Examination date Lung capacity l l FVC l l FEV1.0 l l FEV1.0/FVC. %. % %VC. %. % V25/height (m). l/sec/m. l/sec/m Examination date Blood sampling point Time from blood sampling to completion of analysis Examination for complications: Examination date: Tubercul osis bacteria Erythroc yte sediment ation rate Tuberculi n Evaluation: Smear: Culture: Radiogra Method: phy using a special Observat method 1 hour: 2 hours: mm x mm Examination for complications other than pulmonary tuberculosis Tuberculos is bacteria Phlegm Other findings Phlegm Date Volume Description Sputum Date cytodiagnosi (first day) s Observation Radiography using a special method Minutes Name and address of medical institution To Director of Labour Bureau Name of physician Smear: Culture: ml Smear: Exudate Culture: Method (spiral CT, others ( )) Observation Minutes Seal ml
Form No.9 (Related to Article 57) (3) Report of results of medical examination of a person for whom a Personal Health Record has been issued (chromic acid, etc.) Observation of radiography by using special methods Sputum cytodiagnosis Phlegm, cough, chest pain, nasal cavity ( ), skin ( ) Pathological examination of skin Phlegm, cough, chest pain, others ( ) Observation of nasal cavity Normal Abnormalities in nasal membrane, nasal septum perforation Observation of skin Direct radiography of chest Image 48
Form No.9 (Related to Article 57) (4) Report of medical examination of a person for whom a Personal Health Record has been issued (arsenic trioxide) Date of birth: Liver function test Blood test for red blood cells Measured arsenic content Hair ( ) Urine ( ) Phlegm, cough, stomatitis, diarrhea, constipation, weight loss, paresthesia, skin ( ), others ( ) Observation of radiography using special methods Sputum cytodiagnosis Phlegm, cough, anorexia, weight loss, paresthesia, others ( ) Observation of nasal cavity Pathological examination of skin Observation of skin Pigment anomaly (deposit, depigmentation), cornification, others ( ) Direct radiography of chest Image 49
Form No.9 (Related to Article 57) (5) Report of results of medical examination of a person for whom a Personal Health Record has been issued (coal tar) Observation of radiography using special methods Date of birth: Phlegm cytodiagnosis Phlegm, cough, chest pain, anorexia, skin ( ) Pathological examination of skin Phlegm, cough, chest pain, others ( ) Observation of skin Normal Dermatitis, acne-like lesion, melanoderma, verruca, gaseous spots Direct radiography of chest Image 50
Form No.9 (Related to Article 57) (6) Report of medical examination of a person for whom a Personal Health Record has been issued (bis(chloromethyl) ether) Observation of radiography using special methods Sputum cytodiagnosis Cough, phlegm, chest pain, weight loss Cough, phlegm, chest pain, weight loss Direct radiography of chest Image 51
Form No.9 (Related to Article 57) (7) Report of results of medical examination of a person for whom a Personal Health Record has been issued (beryllium) Physical examination of chest Lung ventilation function test Lung diffusing function test Electrocardiography Respiratory symptom, allergic symptom Dry cough, pharyngeal pain, throat irritation, chest pain, chest uneasiness, shortness of breath, palpitation, difficult breathing, malaise, anorexia, weight loss, others ( ) Observation of skin Lung capacity Beryllium content in urine or blood Skin patch test Hematocrit measurement Direct radiography of chest Image 52
Form No.9 (Related to Article 57) (8) Report of medical examination of a person for whom a Personal Health Record has been issued (benzotrichloride) Observation of radiography using special methods Sputum cytodiagnosis Cough, phlegm, chest pain, nasal discharge, epistaxis, anosmia, sinusitis, nasal polyp, skin ( ), others ( ) Head examination using radiography, etc. Blood test (including hemogram) Histopathological test of lymph nodes Cough, phlegm, chest pain, nasal discharge, epistaxis, anosmia, sinusitis, nasal polyp, swollen lymph node in neck, etc., others ( ) Histopathological test of skin Observation of skin Normal Verruca, pigment deposition, others ( ) Direct radiography of chest Image 53 Name of physician [seal]
Form No.9 (Related to Article 57) (9) Report of results of medical examination of a person for whom a Personal Health Record has been issued (vinyl chloride) Platelet count γ-gtp ZTT IGG LDH General fatigue, fatigability, anorexia, epigastric abnormalities, jaundice, black stools, pallor of finger or hand, hepatic disorder, pain, others ( ) Serum lipid Observation of radiography using special methods Headache, dizziness, tinnitus, general fatigue, fatigability, epigastric abnormalities, jaundice, black stools, pain in finger or hand, others ( ) Liver or spleen scintigram Enlargement of liver or spleen Hepatic function test Neuroclinical examination of central nervous system Direct radiography of chest Image 54
Form No.9 (Related to Article 57) (10) Report of results of medical examination of a person for whom a Personal Health Record has been issued (asbestos) Observation of radiography using special methods Sputum cytodiagnosis Smoking history, quit, currently smokes Cough, phlegm, shortness of breath, chest pain, others ( ) Cough, phlegm, shortness of breath, chest pain, others ( ) Direct radiography of chest Image 55