Medical Examination Route Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

General Patient Information

• Surname

• Full Names

• ID number/ Passport number (non South African Citizen only)

• Employee Number

• Address of Employee
  Address

• Contact telephone number

Employer information

• Tharisa Minerals
  Portion 84 of K/Kraal
  Farm 342JQ
  
  Postnet Suite 473
  Private Bag X51
  Bryanston
  2021

• Are you employed by Tharisa Minerals or Sub Contracting company?

  Tharisa Minerals

  Contractor

• Contractor information

  Select G4S MCC Chrome Carriers Sebetsa BlueSky TCS Johnson Crane hire other

  • G4S
  • MCC
  • Chrome Carriers
  • Sebetsa
  • BlueSky
  • TCS
  • Johnson Crane hire
  • other

• Specify employer details

Occupation

• Jop Title

• Section

  Select Mining Process Dispatch Admin Survey Geology Engineering

  • Mining
  • Process
  • Dispatch
  • Admin
  • Survey
  • Geology
  • Engineering

Physical Enviroment

• Lighting

  Yes

  No

  N/A

• Quantative Measurement

• Qualitative Assessment

• Hours of exposure in a 40 hour week

• Hours of exposure in a 8 hour day

• Noise

  Yes

  No

  N/A

• Quantative Measurement

• Qualitative Assessment

• Hours of exposure in a 40 hour week

• Hours of exposure in a 8 hour day

• Radiation ( non ionizing)

  Yes

  No

  N/A

• Quantative Measurement

• Qualitative Assessment

• Hours of exposure in a 40 hour week

• Hours of exposure in a 8 hour day

• Tempreture Highest

  Yes

  No

  N/A

• Quantative Measurement

• Qualitative Assessment

• Hours of exposure in a 40 hour week

• Hours of exposure in a 8 hour day

• Humidity

  Yes

  No

  N/A

• Quantative Measurement

• Qualitative Assessment

• Hours of exposure in a 40 hour week

• Hours of exposure in a 8 hour day

• Tempreture lowest

  Yes

  No

  N/A

• Quantative Measurement

• Qualitative Assessment

• Hours of exposure in a 40 hour week

• Hours of exposure in a 8 hour day

• Radiation ( non ionizing)

  Yes

  No

  N/A

• Quantative Measurement

• Qualitative Assessment

• Hours of exposure in a 40 hour week

• Hours of exposure in a 8 hour day

• Vibration

  Yes

  No

  N/A

• Quantative Measurement

• Qualitative Assessment

• Hours of exposure in a 40 hour week

• Hours of exposure in a 8 hour day

• Infection

  Yes

  No

  N/A

• Quantative Measurement

• Qualitative Assessment

• Hours of exposure in a 40 hour week

• Hours of exposure in a 8 hour day

• Slippery

  Yes

  No

  N/A

• Quantative Measurement

• Qualitative Assessment

• Hours of exposure in a 40 hour week

• Hours of exposure in a 8 hour day

• Confined spaces

  Yes

  No

  N/A

• Quantative Measurement

• Qualitative Assessment

• Hours of exposure in a 40 hour week

• Hours of exposure in a 8 hour day

• Heights

  Yes

  No

  N/A

• Quantative Measurement

• Qualitative Assessment

• Hours of exposure in a 40 hour week

• Hours of exposure in a 8 hour day

Chemicals

• Exposure to Chemicals

  Yes

  No

• Which Chemicals

Chemical

• Name

Special Requirements

• Item

  Select Gloves Boots protective prescribcion gogles Harness other

  • Gloves
  • Boots
  • protective prescribcion gogles
  • Harness
  • other

1. Body Mass Index

• Weight in kg

• Height in cm

• BMI

2. Skin

• Skin

  Normal

  Abnormal

• Discription of abnormality

3.Cardio Vascular System

• Pulse per minute

• Blood Pressure

• Systolic

• Diastolic

• Heart Sounds

  Normal

  Abnormal

• Murmurs

  yes

  no

4.Resparatory System

• PEF in litres per minute

• Nasal Septum

  Normal

  Abnormal

• Discription of abnormality

• Breath sounds

  Normal

  Abnormal

• Discription of abnormality

• Chest X-rays

  Normal

  Abnormal

• Discription of abnormality

• Lung Function report

  Normal

  Abnormal

• Discription of abnormality

Abdominal Examination

• Urinalysis

• Glucose

  yes

  no

• Protein

  yes

  no

• Blood

  yes

  no

• Nitrate

  yes

  no

6. Vision

• Test Conducted with or without Spectacles

  with Specs

  Without Specs

• Left Eye Acuity

• Right Eye Acuity

• Colour Vision

  Yes

  No

  N/A

• Depth Perception (stereopsis)

  Normal

  Abnormal

• Discription of abnormality

• General inspection

  Normal

  Abnormal

• Discription of abnormality

7. Ears

• Left Ear

  Normal

  Abnormal

• Discription of abnormality

• Right Ear

  Normal

  Abnormal

• Discription of abnormality

• Audiogram Report Left Ear

  Normal

  Abnormal

• Discription of abnormality

• Audiogram Report Right Ear

  Normal

  Abnormal

• Discription of abnormality