Judicial Branch of the Public Power

Superior Council of the Judiciary

Administrative Chamber
Executive Directorate of Judicial Administration IACS

Economic Activity of the Company: Administration of Justice

OCCUPATIONAL MEDICAL RECORDS

Dependency: Department and City: Consecutive History Number

Date: Date: Date: Date:

Medical
Examination Income:__ D M A Newspaper:__ D MA Refund:__ D M A Withdrawa D M A
Occupational: l:__
1. IDENTIFICATION

First and Last Names:____ Identification number: from

______________ Date of birth:
Place of birth:___________ ______________ __________ Sex: F__ M__ Age: ______ __years
Marital status: S__ C__ Sep__ V__ Schooling: Elementary__ High Technique: University: Postgraduate: Profession:
UL_ School__ Middle School__ High School__
_____________ Date of entry: ________________ Seniority:
Position: ______________ _____________ ________________ years
Administrative Travel outside the building Maintenance__ Photocopying__
Main functions:
Telephone answering__ Driving__Other (Which?): ____________________________________ Photocopying__
Photocopying__
E.P.S.(Health): _________ ______________ A.F.P.(Pensions): __ ___________________ A.R.P.(Risks)

2. OCCUPATIONAL HISTORY
Trades performed: Weather Examinations ATEP Sequels Indemnified
Company / Area Occupation / Trade Years Months Eng. Peri. Ret. No No Yes No Yes No Ye Date
s
1.
2.

3.
4.

5.
Current:

Served in the military: Yes_______ No_____ Weather ____________

Describe type of accident, injuries and/or sequelae:

Occupational Disease Qualified by ARP:

T.exposure(h) T. exposure(h) T. exposure(h) T.exposure(h)

Risk Factor Company Risk Factor Company Risk Factor Company Risk Factor Company
1 2 3 4 5 A 1 2 3 4 5 A 1 2 34 5 A 1 2 34 5 A
!

Heat Mists o Fire Attention public.

O
Cold Fumes Lt Explosion Monotony
High illumination Powders Sitting prolonged.
Psicolaboral

Work overload
Electric Ergonom.

Low illumination Liquids Prolonged standing

Chemist
00!sl=l

Pressure Movimi. repetitive Shifts

Rad. Non-ionized Gases and Vapors Levant. of loads High labor rate
Rad. ioniz. Cont. Electric Direct Interpersonal
Noise Contact Chemical Cont. Electric Indirect relationship
Vibration Product Static Load conflict
T. exposure (h) T. exposure (h) T. exposure(h) T. exposure (h)
Risk Factor Company Risk Factor Company Risk Factor Company Risk Factor Company
1 2 3 4 5 A 1 2 3 4 5 A 1 2 34 5 A 1 2 34 5 A
1 ooiBg/oig

Transit Deficient order and Falls

Contact with:
Mechanics
Locative

cleanliness.
Public

Terrorism Animals Installat. poor condition Herra. Manual

Abduction Microorganism Warehouse. deficient Machines
Deportivo Body fluid Cutting elements Projections

Use of Personal Protective Equipment (PPE): Yes: _________ No___ Occasional:___ Occasional:___

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 Judicial Branch of the Public Power
Superior Council of the Judiciary
Administrative Chamber
Superior Council Executive Directorate of Judicial Administration IAC
of the Judiciary
S
Extra-occupational activities:

3. FAMILY HISTORY
Pathology No Yes Relationship Pathology No Yes Relationship
Diabetes Rheumatology
Cardiovascular Neurological
Cancer Mentales
Respiratory Digestive
TBC Others

4. PERSONAL HISTORY
Traumatic Denies Yes Describe Allergy sufferers Denies Yes Describe (agent)
Fractures Asthma
Dislocations Rhinitis
Sprains Dermatitis
Other traumas Urticaria/other
ENT Denies Yes Describe Endocrin./Metabol. Denies Yes Describe
Otitis Dyslipidemia
Sinusitis Diabetes
Hearing loss Enf. Thyroid
Other Obesity/other
Osteomuscular Denies Yes Describe Digestive Denies Yes Describe
Spinal disorders Gastritis
Tendinitis/bursitis Ulcers
S. Carpal Tunnel Colitis
Osteoarthritis/other Others
Infectious Denies Yes Describe Cardiovascular and Denies Yes Describe
respiratory
ETS Hypertension
TBC Infarction
Hepatitis Angina
Zoonoses Epoc
Chronic tonsillitis Bronchitis
Other Varicose veins / other
Neurological / mental Denies Yes Describe Urology Denies Yes Describe
Epilepsy Renal Lithiasis
Migraine/headaches Infecc. Urinary
Psychiatric Tumor Denies Yes Describe
Vertigo/other Toxic Denies Yes
Hematological Denies Yes Transfusional Denies Yes
Surgical Denies Yes Describe Medications Denies Yes

Clarification of personal history:

5. GYNECOBSTETRIC HISTORY
Cycles: / FUM: G: P: C: A: Alive: FUP:
Dysmenorrhea: Yes___ No___ Planning method: __________________________ Latest Cytology:___________________ Last Echo. Mammary:

6. LIFESTYLES
6.1 Smoking: No__Yes__: Occasional to <5:__ Habitual (6-10):__ Compulsive (11 or more):__
Years of habit: 1-5__ 6-10__ 11-20__ >20__ >20__
6.2 Liquor: No_____ Yes___ Occasional________
Ex-smoker_____ Smoking cessation: <1year__ 1-5__ 6-10__ >10years__ 1-5__ 6-
10__ >10years__ 1-5__ 6-10__ >10 years 6.3 Drug addiction: No_____ Yes____ Type of drug:____________________

6.4 Exercise Habits: No__________ Yes___ Which one?_______________________________________ Frequency:_______________________

Sports injuries: No___________ Yes___ Which one?_____________________________________________________________

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 Judicial Branch of the Public Power
Superior Council of the Judiciary
Administrative Chamber IAC
Executive Directorate of Judicial Administration S

7. REVIEW BY SYSTEMS
System N S Describe System N S Describe
Sense organs Gastrointestinal
Neurological / mental Genitourinary
Cardiorespiratory Osteomuscular
Metabolic and endocrine Skin and adnexa

8. PHYSICAL EXAMINATION
Weight: _____Kg. Height: ____________meters BMI:_________ P.A: ____________/ ______ Pulse: __________ F.R:_____________
General condition: Normal_____ Abnormal _____ Mental Status: Normal______ Abnormal_____ Right-handed: ___ Left-handed: ___ Ambidextrous:
___
8.1 Head
Normal Abnormal Describe Normal Abnormal Describe
Skull
Inspection
Eyelids Mucosa
Conjunctiva Partition
Scleras Nose Bugles
Eyes
Cornea Breasts
Paranasal
Iris-pupils
Fundus Palate
Pavilions Mucosa
Ears Ducts Language
Eardrums Tonsils
Visiometry Remarks Orofa- Pharynx
Snellen Letter OD OI AO ringe Denture

Nearby 20/ 20/ 20/ Superior:_______

Far 20/ 20/ 20/ Prosthesis Inferior:________
Correction 20/ 20/ 20/ Total:__________
8.2 Neck Normal Abnormal Describe
Inspection
Palpation
Adenopathies
Thyroid gland
8.3 Chest Normal Abnormal Describe Normal Abnormal Describe
Inspection Inspection
Palpation Palpation
Percussion Mammary Nipples
gland
Pulmonar Scars
y Auscultation
Secretion
Heart Normal Abnormal Describe
P.M.I

Rhythm
Noises

Murmurs
8.4 Abdomen Normal Abnormal Describe
Inspection
Palpation (Megalias)
Percussion
Auscultation
Masses
Hernias
8.5 Genitourinary Normal Abnormal Describe Normal Abnormal Describe
Inspection Inspection
Pubic hair Pubic hair
Man Woman
Testicles TV / TR (if
applicable)
TR (if applicable)

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 Judicial Branch of the Public Power
Superior Council of the Judiciary
Administrative Chamber IAC
Executive Directorate of Judicial Administration
S

8.6 Osteomuscular
Senior Members Lower Limbs
Abnormality PHALEN TINNEL Abnormality Inspection:
Movement Movement
Homb. Elbow Muñec Fingers D I D I Cader Knee Cll foot Finger Atrophy: No___ Yes___ Which one?____________
arcs arcs s
D I D I D I D I (-) (+) (-) (+) (-) (+) (-) (+) D I D I D I D I Hypertrophy: No___ Yes___ Which one?________
Palpation: Normal___ Abnormal___ Normal___
Flexion (-)=NEGATIVE (+)=POSITIVE Flexion Abnormal___ Normal___ Abnormal
Extension Inspection: Extension Sensitivity: Normal___ Abnormal___
Abduction Atrophy: No___ Yes___ Which one?_________ Abduction RUNNING: Normal______Abnormal________
Adduction Hypertrophy: No___ Yes___ Which one?_____ Adduction Clauidication:____________________________
Palpation: Normal___ Abnormal___ Normal___
Rot. internal Abnormal___ Normal___ Abnormal___
Rot. Internal Help:___________________________________
Rot. external Sensitivity: Normal___ Abnormal___ Rot. Extern.
Pronation Investment
Supination Eversion
Desv. ulnar Abnormal structures (congenital, amputations, deviations, masses, pain, fractures):
Desv. radial
Opposition i
8.7 Spine
Curved Cervical Dorsal Lumbar Scoliosis Cervical Dorsal Lumbar Special tests
Region
NAD N A D NAD No Yes No Yes No Yes Schöber test (lumbar mobility): _______cm.
Kyphosis Right Wells test (hamstring): ___________degrees
Lordosis ii ii Left Negat. Posit.
Cervical Dorsolumbar Pain Spasm Lassegue
Movement arcs
Normal Anorm. Normal Anorm. No Yes No Yes Valsalva maneuver
Flexion Neri Maneuver
Extension Wassermann maneuver
Right rotation Spurlin maneuver
Left rotation Patrick's maneuver
Right lateral tilt Nigram maneuver
Left lateral tilt Wadell
Muscle Balance Retracted structures
Abdominal muscle strength: Normal___ Abnormal___ Abnormal___ N ______
Yes____
Abnormal___
Strength Abnormal___
of dorsal muscles: Abnormal___ Abnormal___ Abnormal___ Abnormal___
Normal___ Abnormal___
Abnormal___ Abnormal___ o
neación Scapular:__________Pelvic Alignment:____________
Abnormal___ Abnormal___ Abnormal___ Abnormal___ Abnormal___ Abnormal___ Abnormal___ Al
Reflections Normal Abnormal Describe
Bicipital
Tricipital
Patelares
Aquilianos
Neurological examination
8.8 Peripheral vascular. Normal Abnormal Describe
Peripheral pulses
Varicose veins
8.9 Skin and flanks Normal Abnormal Describe
Scars
Tattoos
Nevus
Acne
Nails
Dermatoses / other

9. LABORATORY TESTS
Examination Date Result Examination Date Result
1. 4.

2. 5.
3. 6.
Annotations: Hemoclasification:

10. IMMUNIZATIONS
Vaccine Date Next dose Vaccine Date Next dose

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 Judicial Branch of the Public Power
Superior Council of the Judiciary
Administrative Chamber IAC
Superior Council
of the Judiciary
Executive Directorate of Judicial Administration S

11. DIAGNOSTICS
1.
2.
3.
4.
5.
6.
7.

12. RECOMMENDATIONS

Use of protective equipment recommended for the Eyes Ears Cara Head Respirac/n Suit Other (Which one?)
work assigned:

13. MEDICAL CONCEPT OF ADMISSION / REIMBURSEMENT

Concept Remarks
Apt
Suitable with restrictions that do not interfere with your normal job
Suitable with restrictions limiting their normal work
Postponed
Not suitable
Requires relocation: No___ Yes___ Yes___ Yes___ Yes___
___________________________________
Yes___ Yes___ Yes___ Yes___ Yes___ Yes___ Yes___ Yes___

14. PERIODIC MEDICAL CONCEPT

Normal: Yes___ No___ Describe:___________________________________ Referral: No___ Yes___ EPS____________ _______ ARP_____________________

15. MEDICAL CONCEPT OF RETIREMENT

Normal: Yes___ No___ Describe:___________________________________ Referral: No___ Yes___ EPS____________ _______ ARP_____________________

Under oath I affirm that all the information provided above is correct and that I have not concealed anything about my health history.

Note: in case of any inaccuracy due to omission or because of the interested party, he/she will be subject to the penalties provided by law.

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Code:F-AGH-07 Version: 00 P. 8 out of
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Economic Activity of the Company: Administration of Justice

Dependency:

Occupational Medical Examination:

1. IDENTIFICATION
First and Last Names:_______________________________________ Identification number:________________ from _____
Place of birth:_______________________ Date of birth:______________________ Sex: F__ M__ Age: ________________añ
Marital Status: S__ C__ UL__ Sep__ V__ Schooling: Elementary__ High School__ Technical__ University:__ Graduate:__
Profession:_ Position: ________________ Date of entry: ___________________________ Seniority: _______________years
Main functions:
E.P.S.(Health): ______________________
Extra-occupational activities:

3. FAMILY HISTORY
Pathology N
Diabetes
Cardiovascular
Cancer
Respiratory
TBC
4. PERSONAL HISTORY
Traumatic Nie

Fractures
Dislocations
Sprains
Other traumas
ENT Nie

Otitis
Sinusitis
Hearing loss
Other
Osteomuscular Nie

Spinal disorders
Tendinitis/bursitis
S. Carpal Tunnel
Osteoarthritis/other
Infectious Nie

ETS
TBC
Hepatitis
Zoonoses
Chronic tonsillitis
Other
Neurological / mental Nie

Epilepsy
Migraine/headaches
Psychiatric
Vertigo/other
Hematological Nie
Surgical Nie

Clarification of personal history:

5. OBSTETRICS AND GYNECOLOGY HISTORY

Cycles: / FUM:
Dysmenorrhea: Yes___ No___

6. LIFESTYLES
6.1 Smoking: No__Yes__: Occasional to <5:__ Habitual (6-10):__ Compulsive (11 or more):
 Years of habit: 1-5__ 6-10__ 11-20__ >20__ >20
Ex-smoker_____ Smoking cessation: <1year__ 1-5__ 6-10__ >10years__ 1-5__ 6-10__ >10years__ 1-5__ 6-10__ >10 years
6.4 Exercise habits: No_________ Yes________ Which one?_____________________________________ Frequency:___________________
Sports injuries: No Yes Which one?

7. SYSTEMS REVIEW
System
Sense organs
Neurological / mental
Cardiorespiratory
Metabolic and endocrine

8. PHYSICAL EXAMINATION
Weight: _____Kg. Height: _________meters
General condition: Normal____ Abnormal_____
8.1 Head
Skull

Eyelids
Conjunctiva
Scleras
Eyes
Cornea
Iris-pupils
Fundus
Pavilions
Ears Ducts
Eardrums
Visiometry
Snellen Letter OD
Nearby 20/
Far 20/
Correction 20/
8.2 Neck
Inspection
Palpation
Adenopathies
Thyroid gland
8.3 Chest
Inspection
Palpation
Percussion
Pulmonary
Auscultation

Heart
P.M.I
Rhythm
Noises
Murmurs
8.4 Abdomen
Inspection
Palpation (Megalias)
Percussion
Auscultation
Masses
Hernias
8.5 Genitourinary
Inspection
Pubic hair
Man
Testicles
TR (if applicable)

8.6 Osteomuscular
Senior Members
Abnormality
Movement arcs Homb. Elbow Mu

D I D I D
Flexion
Extension
Abduction
Adduction
Rot. internal
Rot. external
Pronation
Supination
Desv. ulnar
Desv. radial
Opposition
8.7 Spine
Curved Region Cervical Dorsal
A D
N N A
Kyphosis
Lordosis 1 1

Movement arcs

Flexion
Extension
Right rotation
Left rotation
Right lateral tilt
Left lateral tilt

Abdominal muscle strength: Normal___ Abnormal___ Abnormal___ Abnormal___ Abnormal___ Abnormal___

Abnormal___ Abnormal___
Strength of dorsal muscles: Abnormal___ Abnormal___
Normal___ Abnormal___ Abnormal___ Abnormal___ Abnormal___ Abnormal___
Abnormal___ Abnormal___ Abnormal___ Abnormal___
Reflections
Bicipital
Tricipital
Patelares
Aquilianos
Neurological examination
8.8 Peripheral vascular.
Peripheral pulses
Varicose veins
1. 9 Skin and flanks
Scars
Tattoos
Nevus
Acne
Nails
Dermatoses / other

10. IMMUNIZATIONS
Vaccine

13. MEDICAL CONCEPT OF ADMISSION / REIMBURSEMENT

Apt
Suitable with restrictions that do not interfere with your normal job
Suitable with restrictions limiting their normal work
Postponed
Not suitable
Requires relocation: No___ Yes___ Yes___ Yes___ Yes___ Yes___ Yes___ Yes___ Yes___ Yes___ Yes___ Yes___
Yes___ Restrictions:

14. PERIODIC MEDICAL CONCEPT

INormal: Yes___ No___ Describe:______________________________
15. MEDICAL CONCEPT OF RETIREMENT
Normal: Yes___ No___ Describe:_________________________________

Under oath I affirm that all the information provided above is correct and that I have not concealed anything.

Signature
Administrative Moving out of the building Maintenance Photocopyin
g

Trades performed:

Use of Protection Elements

o Yes

ga Yes

ga Yes

ga Yes

ga Yes

ga Yes

ga Yes

ga Yes

] G:
Planning method: ________________________
 N S

BMI:_________

Normal Abnormal

OI AO
20/ 20/
20/ 20/
20/ 20/
Normal Abnormal

Normal Abnormal

Normal Abnormal Describe

Normal Abnormal Describe

 Normal Abnormal

PHALEN

ñec Fingers D I

I D I (-) (+) (-) (+)

Inspection:
Atrophy: No___
Yes___ Yes___ Which one?_______

Hypertrophy: No___ Yes___ Which one?____

Abnormal___ Abnormal___ Abnormal___ Abnormal___
Palpation: Normal___ Abnormal___ Abnormal___ Abnormal___ Abnormal___
Sensitivity: Normal Abnormal___ Abnormal___ Abnormal___ Abnormal___
Abnormal___ Abnormal___ Abnormal___ Abnormal___

—
Abnormal structures (Congenital, amputations, amputations,
— deviations, m

Lumbar
N D
D A
Right
Left
Cervical
Normal Anorm.

Muscle Balance

Normal Abnormal Describe

Normal Abnormal Describe

Normal Abnormal Describe

Concept
about my health history.

and the examinee's

identity card
 Department and City:

_ Telephone answering__ Driving__Other (Which?): __________________________________

A.F.P.(Pensions): _____________________

Occupation / Trade

T. exposure(h)
Company
1 2 3 45 A

T. exposure (h)
Company
1 2 3 45 A

Occasional:___
Personnel (PPE): Yes: __ No___ Occasional:___
Relationshi
p

Describe

Describe

Describe

Describe

Describe

Describe

] ]
P: C:
 Describ
e

P.A: ______/_
Mental Status: Normal______
Abnormal

Describe

Remarks

Describe

Describe
 Describ
e

Inf Members
TINNEL

D I

(-) 1 (+) (-) 1 (+)

(-)=NEGATIVE (+)=POSITIVE Flexion
Extension
Abduction
Adduction
Rot. Internal
Rot. Extern.
Investment
Eversion
asas, pain, fractures):

Scoliosis Cervical Dorsal

No Yes No S

Dorsolumbar Pain
Normal Anorm. No S
 Result

Next dose

Eyes Ears
 Judicial Branch of the Public Power

OCCUPATIONAL MEDICAL RECORDS

Newspap D M A
er:

Date:
Weather
Years Months Eng.

Factor of
Risk
Fire
FQc

Explosion
Sitting prolonged.
Ergonom.

Prolonged standing
Movimi. repetitive
Levant. of loads
Cont. Electric Direct
Electric

Cont. Electric Indirect

Static Load

Risk Factor

Deficient order and

cleanliness.
Locative

Installat. poor
condition
Warehouse. deficient
Cutting elements
 Judicial Branch of the Public
Power Pathology
Rheumatology
Neurological
Mental
Digestive
Others

Allergy sufferers
Asthma
Rhinitis
Dermatitis
Urticaria/other
Endocrin./Metabol.
Dyslipidemia
Diabetes
Enf. Thyroid
Obesity/other
Digestive
Gastritis
Ulcers
Colitis
Others
Cardiovascular and respiratory
Hypertension
Infarction
Angina
Epoc
Bronchitis
Varicose veins / other
Urology
Renal Lithiasis
Infecc. Urinary
Tumor
Toxic
Transfusional
Medications

]A: Alive:
Latest Cytology:__________________
6.2 Liquor: No____ Yes___ Occasional_______
6.3 Drug addiction: No____ Yes____ Type of drug:___________________

Judicial Branch of the Public Power

System
Gastrointestinal
Genitourinary
Osteomuscular
Skin and adnexa

Pulse:________

Inspection
Mucosa
Partition
Bugles
Nose
Breasts
Paranasal
Palate
Mucosa
Language
Tonsils
Pharynx
Orofa-ringe Denture

Prosthesis

Inspection
Palpation
Mammary gland Nipples
Scars
Secretion
 Inspection
Pubic hair
Woman

TV / TR (if applicable)

Judicial Branch of the Public Power

eriores
Abnormality
Movement arcs Cader Knee Cll
D I D I D

Lumbar Special tests

i No Yes Schöber test (lumbar mobility):
Wells test (hamstring):

Spasm Lassegue
i No Yes Valsalva maneuver
Neri Maneuver
Wassermann maneuver
Spurlin maneuver
Patrick's maneuver
Nigram maneuver
Wadell

No_____ Yes___________
Scapular Alignment:
__________________________
 Examination
4.
5.
6.

Vaccine

Judicial Branch of the Public Power

Cara Head
Referral: No___ Yes___ EPS________________ ARP__________________

Referral: No___ Yes___ EPS________________ ARP____________________

 Date:
Reimburs D M
ement:

A.R.P.(Risks): ______________________

Examinations AT
Peri. Ret. No No

T. exposure(h)
Company
1 2 3 45 A

Psicolaboral

T. exposure(h)
Company
1 2 3 45 A
Mechanics
 No Yes

Denies Yes

Denies Yes

Denies Yes

Denies Yes

Denies Yes

Denies Yes

Denies Yes

Denies Yes

Denies Yes

FUP:
N S

F.R:____________
Right-handed:
___

Normal Abnormal

Superior:______
Inferior:_______
Total:_________

Normal Abnormal
 Normal Abnorma
l
Inspection:

foot Fingers Atrophy: No___ Yes___ Which one?________

I D I Hypertrophy: No___ Yes___ Which one?_____

Palpation: Normal___ Abnormal___
Normal___ Abnormal___ Normal___
Sensitivity: Normal___ Abnormal___

RUNNING: Normal______Abnormal_______

Clauidication:__________________________

Help:________________________________

______cm.
___________degrees

pelvic training:____________
Respirac/n

Remarks
Name, signature and r
 Consecutive History Number
-

Withdrawal:

EP Sequels
Yes No Yes No Yes

—
Risk Factor
1 2
Attention public.
Monotony
Work overload

Shifts
High labor rate

Conflict
interpersonal relationship

Risk Factor
1 2
Falls
Herra. Manual
Machines
Projections
 Relationshi
p

Describe (agent)

Describe

Describe

Describe

Describe

Describe

Last Echo.
Mammary:
 Describe

Describe

Left- Ambidextrou
hande s:
d:
Describe
 Describ
e

Retracted structures
 Result

Hemoclasification:

Next dose

Suit Other
(¿?
ector's Record
Date:
D M A

Indemnified
Date

T.exposure(h)
Company
3 45 A

T. exposure (h)
Company
3 45 A
Posit.
Which
one?)