Agilent Technologies LDA 60 (4) 680 3888 (telephone)Malaysia Sdn. Bhd. (1075825-M), 60 (4) 680 3708 (fax)Bayan Lepas Free Industrial Zone, www.agilent.com11900 Penang, Malaysia.

Date : _________________

Klinik Singapore Sungai Ara-Relau Klinik Aman

823-G-03, Kejora Business Point 11 Jalan Sultan Azlan Shah

Jalan Paya Terubong MK 13 11700 Penang

11900 Bayan Lepas, Penang (24 Hours)

(9.00am to 1.00pm, 2.00pm to 10.00pm) Tel: 04 6581361

Tel: 04 6448488

Klinik Joe Fernandez (Tmn Jaya) Klinik Aman

No. 30-1, Taman Jaya 603 Jalan Dato Kramat

Jalan Kulim 10150 Penang

14000 Bukit Mertajam (Mon-Sun 9.00am to 9.00pm)

(Mon-Fri 24 Hours) Tel: 04 2291844

(Sat, Sun, P. Holiday : 24 Hours)

Tel: 04 5395217/04 5386439/04 5386448

Others, Non-Agilent Panel Clinic Klinik Singapore

71F Trengganu Road

10460 Penang

(24 Hours)

Tel: 04 2810114

Dear Doctor,

Kindly conduct Physical Examination, Routine Urine Examination and Chest X-Ray on

Mr./Miss/Madam : ___________________________________

I.C. No. : ___________________________________

and bill us accordingly. (Agilent Technologies panel clinic only)

Yours Faithfully, Note to Clinic and Candidate:

* Candidate to print all 5 pages of the form single sided

* Clinic to detach and collect page 1

* Routine urine examination EXCLUDE urine cannabinoids or morphine

* Expenses for other diagnostic tests not required in this pre-employment check-up

_____________________________ will be borne by candidate

HUMAN RESOURCE DEPARTMENT * Official receipt is required for reimbursement if payment is made by candidate

* Candidate to submit claim at in-house clinic

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PRE-EMPLOYEMENT HEALTH QUESTIONNAIRE (To be filled up by employee)

Name : __________________________ Age : ______________ Date of Birth : ____________

I.C. No. : __________________________ Gender : ______________ Marital Status : ____________

Phone No. : __________________________ SOCSO No. : ______________ Employee No. : ____________

Job Title : __________________________ Department : ______________ Date of Hire : ____________

YES NO

1. Are you presently taking any prescribed medication? If "YES", explain:

_________________________________________________________________________________________

2. Have you been admitted to hospital before? If "YES", give reasons and dates:

_________________________________________________________________________________________

3. Have you undergone surgical operation previously? If "YES", give reasons and dates:

_________________________________________________________________________________________

4. Have you ever been discharged from another company for health reasons? If "YES",

describe and give dates:

_________________________________________________________________________________________

5. Have you ever been injured in an automobile or motorcycle accident before? If "YES",

describe and give dates:

_________________________________________________________________________________________

6. Is there any work that you cannot perform for any physical reasons? If "YES", explain:

_________________________________________________________________________________________

7. Have you ever had a job where you were exposed to excessive noise, dust, fumes

or to other conditions which might have an effect on your health?

If "YES", describe and give dates:

_________________________________________________________________________________________

8. Do you smoke? If "YES", how many cigarettes per day?

_________________________________________________________________________________________

9. Are you pregnant? IF "YES", how many months pregnant? (X-Ray is not recommended for pregnant women)

_________________________________________________________________________________________

10. Date of your last menstrual period : __________________

I understand that my employment is contingent upon the accuracy of the information given and it will be used as part

of my Personal Record. I hereby certify that all information furnished on this form is true, complete and correct to the

best of my knowledge. I understand that if any false statement is made, the Company reserves the right to terminate

my employment instantly. I hereby acknowledge that my pre-existing medical condition will not be covered

by Agilent Technologies Group Hospitalization & Surgical Plan for the first 12 months of my employment.

Applicant's Signature Date

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Name : ___________________________

PRE-EMPLOYMENT MEDICAL REPORT (To be filled up by doctor)

Personal History :

_________________________________________________________________________________________

Family History :

_________________________________________________________________________________________

Drug History :

_________________________________________________________________________________________

Any history of the following :

YES NO YES NO

1. Hypertension 11.Gastric/Stomach Problems

2. Diabetes 12. Emotional Disorder/Hysteria

3. Heart Disease/Pacemaker 13. Hearing Problem

4. Leukemia/Thalassemia/ 14. Migraine/Frequent Headache

Hemophilia 15. Dizziness/Fainting spells

5. SLE 16. Hernias

6. Kidney Problem 17. Allergies/Rashes

7. FITS/Epilepsy 18. Thyroid

8. Tuberculosis 19. Hepatitis

9. Asthma/Difficulty in Breathing 20. Any Physical Disabilities

10. AIDS

Relevant/Medical History :

_________________________________________________________________________________________

Remarks :

_________________________________________________________________________________________

Occupational History : (Exposure to High Noise, Lead, Radiation, Dust etc)

_________________________________________________________________________________________

Physical Examination

Weight : _________________ Skin : _________________ Vision : Left Right

Height : _________________ Eye : _________________ Distance _____ _____

Lung : _________________ Chest : _________________ Reading _____ _____

Heart : _________________ Back : _________________ Color _____ _____

CNS : _________________ ENT : _________________

Abdomen : _________________ Dental : _________________

Head/Neck : _________________ Joints : _________________

Limbs : _________________

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Name : ___________________________

Blood Pressure : _________________

General Condition : _________________

Pelvic Examination (Female) : _________________

Results of Investigation Done

Urine Examination : ____________________________________________________________________

Chest X-Ray : ____________________________________________________________________

Suitable for scope work YES Comments : ___________________________________________

NO ___________________________________________

___________________________________________

This is to certify that I have examined the above named and the following abnormalities/health concern

were noted:

FIT: UNFIT:

Comments :

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Doctor's Signature : ______________________

Doctor's Name : ______________________

Date : ______________________

Clinic's Stamp

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DEPENDANT'S OUTPATIENT REGISTRATION FORM (For permanent employee only)

Name of Employee : __________________________________________________

Employee No. : ______________________

I.C. No. (Employee) : ______________________

Name of Spouse : __________________________________________________

Date of Birth (Spouse) : ______________________

Name of Children I.C. No. Date of Birth Gender

1. ________________________ _________________ ________________ ________

2. ________________________ _________________ ________________ ________

3. ________________________ _________________ ________________ ________

4. ________________________ _________________ ________________ ________

5. ________________________ _________________ ________________ ________

Note: Please complete a new form for any change or addition of dependants.

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