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PRE.SEA AND PERIODIC MEDICAL FITNESS ASSESSMENT OF SEAFARER

Examinee's Personal Declaration (Assistance should be offered by medical staff)Have you ever had any of the following conditions?

No. Seafarer lnformationL Name (last, first, middle): LATIF, ABDUL AZIS2 Place and Date of binh (d/m/v): 02104119703 gsxs Male4 Home Address: JL H.JUHRI NO 8 RT 02 RW 08 MERUYA SELATAN

KEMBANGAN JAKARTA BARATHome Phone: Mobile Phone: Affi28187 4776Email:

5 Passport No.: A 0187640 Seafarer's book No.: B 0518946 Nationality: INLTUNt SIAI\7 Department: uA I tsl'(lNG8 ft3nft; CO()K - SeaIarer9 Duties (if known): ROUTINE10 Type of ship: sUKvtsY Vts$SbLLL Trade area: WORLDWIDEt2 Principal / Manning Asent: PT. SAMUDERA INOVASI PERSADA

Do you smoke, use alcohol

ration / Su

Varicose veins / Piles Dizziness / FainAsthma / Bronchitis Loss of consciousness

Attempted suicide

Back or ioint oroblem

Fractures / Dislocationslf you answered "yes" to any of the above questions, please give details:

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No. Additional Questions Yes No35 Have you ever been signed off as sick or repatriated from a ship? t/35 Have you ever been hospitalized? l"/37 Have you ever been declared unfit for sea duty?38 Has your medical certificate even been restricted or revoked? t/39 Are you aware that you have any medical problems, diseases or illnesses?40 Do you feel healthy and fit to perform the duties ofyour designated position /

occupation?4t Are you allergic to any medication?

Comments:

42 Are you taking any ngn-prescription or prescription medications? {t/lf yes, please list the medications taken, and the purpose(s) and dosage(s):

I hereby certify that the personal declaration above is a true statement to the best of myknowledge. I

signature of examinee , fut

Witnessed by (signatur q,l\ ilW

Date (d/m/y\ 17 t03t2015

Name: 0, 1tlq

I hereby authorize the release of allprofessionals, health institutions and

my previous medical records from any healthpublic authorities to Dr. Rudy Kastono (the

a pproved medical practitioner!.

Signature of examinee: Date (d/m/y): 17 t03t20 1 5

Name:: $1 "f./{/ _witnessed by (signatur*,

[UU4Date and contact details for previous medical examination (if known):

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JL. TEBET TIMUR DALAM RAYA NO. 58, JAKARTA 12820, INDONESIATEL.: +62-21-8297255 - 83791386 - FAX.: +62.21-83791518 - www.assaadah-clinic.com

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MEDICAL EXAMINATIONSight:Use of glasses or contact lenses: (if yes, specify which type and for what purpose):

Visual Fields:Normal Defective

Right EyeLeft Eve

Colour Vision:I Not tested

"p Normal E Doubtful E Defective

Hearing:Pure tone and audiometry (threshold values in dB)

500 Hz 1,000 Hz 2,000 Hz 3,000 HzRieht Ear )o )n 4n oiLeft Ear 1q ,IE 4F .lE

and Wh testNormalSpeech Whisper

Rieht Ear 3 2Left Ear 3 )

VitalSigns UrinalvsisHeisht Weieht Pulse Rhythm BP Protein Blood Glucose

162 cm 65 ke 88 lmt {ORMAL 30/Rn {ORMAI {ORMAI {oRt\ral

Review of Systems N A Review of Systems N AHead / Skin fSinuses, Nose, Throat , Varicose veinsMouth/Teeth , VascularEars (general) f Abdomen and VisceraTympanic membrane f HerniaEyes f Anus (not rectalexam)Ophthalmoscopv G-U systemPupils , Upper and Lower extremitiesEve movement a Spine (C/S, T/S and L/S)Lungs and Chest a Neurolosic (ful l/brief)

A''A'APAH IAT D[(At (ENTRE"seryicing from tfre S{LART'

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Chest X-ray:I Not oerformedRe s u lt :' ..f!9,n.Y.11t

tPurforrn.d on (d/m/yl 17103t2015

Breast examination Psychiatric {Heart ! General appearance {

Other diagnostic test(s) and result(s): (see attachments)No. Test Not performed Performed N A

1 Tuberculin or IGRA Test {2 Spirometry ,l3 ECG { {4 Stress Test {5 Step-up FitnessTest {6 USG Abdomen {7 Hematology { {8 Serology { {9 Clinical Chemistrv { {10 Drugs Test ,ltI Stool (OP test and/or Culture) { {!2 Stool Hemoccult { {13 Prostate Specifi c Antigen J74 Presnancv Test15 Papanicolaou Smeart6 MammosraphvL7 Other: .........

Medical practitioner's comments and assessment of fitness, with reasons for any limitations:Fit for sea services / offshore-onshore work with no restrictions

Assessment of Fitness for Service at Sea

On the basis of the examinee's personal declaration, my clinical examination and thediagnostic test results recorded above, I declare the examinee medically:d fit for look-out duty I Not fit for look-out duty

Deck Service Engine Service Caterins Service Other ServicesFit {Unfit

{ Without Restriction I With Restriction Visualaid required 0 Yes { No

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.]1. TEBEI TIMIJR DALAN/ RAYA NO. 58, JAKARTA 12820, INDONESIATEL" : +62-21-8297255 - 83791386 - FAX.: +62-21-83791518 - www.assaadah-clinic.com

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Describe restrictions (e.9., specific position, type of ship, trade area

M ed ica I ce rtifi cate's date of expi rati on (d I mlVl : 17 I 0312017Date medical certificate issued ldlmlVl: 1710312015Number of medical certificate: 2415A31700021

Medical practitioner information:Name: Dr. Rudv KastonoLicense number: 3111100211009798Address: jl. Tebet Timur Dalam raya No.58, Jakarta t2820,lndonesiaSignature of medical practitioner: t!

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Registration Number Date of Examination2015031700021 7 March 2015

Blood Result Normal Reference Blood Chemistrv Result Normal ReferenceBlood group A+ Random blood sugar 32OO mg/dlHemoglobin 14.7 Male: 13.8 - 17.2 g/dl Fasting blood sugar 113 < 140 mgldl

Female: 12.0 - 15.6 C/dl 2hr-pp blood sugar <200 msldlHematocrit Male: 42 - 52% Serum creatinine 1.50 Male: s 1.2 mgldl

Female:31 -48yo Female: < 1 mg/dlRed blood cells 4.9 Male:5.4 t 0.8 million/ml AST / SGOT 17 < 47 tU/L

Female:4.8 t 0.6 million/ml ALT / SGPT 17 < 48 rU/L

White blood cells 4.9 4.3 - 10.8 million/ml Alkaline phosphatase 30 - 72O U/LM.C.V 82 - 92 Cu MiC Total cholesterol s 200 mg/dlM.C.H 27 -31,Yico gr HDL cholesterol > 40 mg/dlM.C.H.C 32 -37% LDL cholesterol < 130 mg/dlReticulocytes 0.5 -1..s% Triglycerides s 169 mgldlESR (Westergren) Male: < 20 mm/h Total lipids s00 - 1000 mgldl

Female: < 25 mm/h Albumin 3.s - s.3 grldlOther ....................... Globulin I.3 -2.7 gr/ml

Total protein 6-8gr%Microscopy Result Normal Reference Direct bilirubin 0 - 0.5 mg/dl

Basophils 0 o -3% lndirect bilirubin 0 - 0.5 mgldlEosinoph ils 0 o -5% Total bilirubin < 1.2 mg/dlMyelocytes neutrophils 0 0o/o Urea 31 s - a8 mgldlMetamyelocytes N's 0 o -t% Uric acid 2.s - 7.7 mc/dlBand neutrophils 4 o - 8a/, Sodium 135 - 1.55 meq/lSegmented neutrophils 65 34 -75% Potassi um 3.4 - 5.3 meq/lLymphocytes 26 12 -s0% Calcium 8.5 - L0.40 mg/dlMonocytes 5 3 - 15a/. Chloride 95 - 111 mmol/lThrombocytes 1s0,000 - 3s0,000 sL Carbon dioxide 32 - 46 mg/llmmature WBC NEG Negative LDH 80 - 240 mU/mlAbnormal RBC NEG Negative V G,T Male:8 - 37 lUllMalaria NEG Negative Female: 6 - 42lU/lFila ria NEG Negative Other ............,...........Other ........................

Notes: NR = Non-reactlve; R = Rr )active

A'SA'APAH &&H Pr(AU" EENTRE*'servicing from tfre S{EAKT"JL.. TEBET TIMUR DALAM RAYA NO. 58, JAKARTA 12820,INDONESIA

TEL.: +62-21-8297255 - 83791386 - FAX.: +62-21-83791 518 - www.assaadah-clinic.comEmail : admin@assaadah-clinic.com

Certificate of Hvqiene Fitness for Food Handler

This is to certify that ABDULAZTS LATIF has done medical examination at our clinic onMARCH t7, zOtS withthe result is FIT FORSEASERVICES as COOKHe/she is at present:1. FREE from the symptoms or signs of Typhoid and Paratyphoid Fever, such as:o Fever l 38s Celcius (> 100.4' Fahrenheit)

o Headacher Nause or Vomitingo Diarrhea or Constipationo Abdominal Cramps or Tenderness. Hepato-splenomegalyr Bradycardiao Rose Spots

2. NORMAL TITER for Widal Agglutination Testing.3. FREE from food-borne (fecal-oral transmission) parasites & pathogens:

No Examinations Results1 Hepatitis A - HAV(lgM) Negative2 StoolOccult Blood Negative

3Ova & Parasites(O&P test):

a) Roundworms: Ascaris lumbricoides Negativeb) Hookworms: Necator americanus Negativec) Pinworms: Enterobius vermicularis Negatived) Tapeworms: Diphyllobothrium latum,

Taenia saginata, and Taenia soliumNegative

e) Protozoa: Entamoeba histolyticaGiardia lamblia

and Negative

4 Stool culture a) Salmonella sp. Negativeb) Shigella sp. Negativec) Escherichia coli (O157:H7 and O104:H4) Negatived) Vibrio cholerae Negative

Jakarta, 19 MARCH 2015

Assa'adah Medical Centre

Dr.Chief Physician

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Registration Number Name Date of Examination201 5031 700021 BDUL AZIS LATIF 17 March 2015

\TORt.UM 2Urine Result Normal Reference Serology Result Normal Reference

Protein NEG Negative Reagin (VDRL or RPR) NR Non- reactiveReduction NEG Negative TPHA NR Non-reactiveBlood NEG Negative Ntn ---------++eft+eaetiv€Bilirubin NEG Negative HBsAg NR Non- reactiveKetones NEG Negative A€iLH,c\l--. Nt tr) *--[{sn*E€aet&eN itrites NEG Negative HIV NR Non- reactiveSediment NEG Negative ^tD --*-+{€r--rei)€ti+eCytology NEG Negatjve Other ........................

B-HCG (female) Negative

PAP smear (female) Negative

Casts NEG Negative

Bacteria NEG Negative

Crysta ls NEG Negative

Albustix NEG Negative

Color Yellow Pure Yellow

Urobilin 0- 1+

DHI-+----..1Soecific eravitv l

WBC I

RBCrIapr,rlera""TOtf,.r...4

.,Notes:,NR = Non-reactive; R = Reactive

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4.8 - 8.0

1005 - 1030

a-20-2

We declare the above-named examinee,s laboratory test is/tr Normal I L-.t Abnormal

A''A'ADAH iTE DICAT CENTBE((a ' r tfie?{TAkf'servLCLTLg JrovnJL. TEBET TIMUR DALAM RAYA NO" 58, JAKARTA 12820,INDONESIA

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Registration Number Date of Examination

UL AZIS LATIF 17 March 20'15

Resti ECGA l"2-lead ECG should be performed only for all seafarers over the age of 40, have hypertension, orrhythmio or irregulor pulseand in the younger condidotes with cardioc murmurs, cardiomeqoly or symptoms suqqestive of mvocordiol ischemia

We declare the above-named examinee's ECG test is:

tr Abnormalities in rate tr Abnormalities in rhythm n Cardiac myopathy

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Oral & Dental

Name: ABDUIAZIS LATIFDate: 17 MARCH 2015

tdult Ieeth{Ipper ?eefil.Csrtlrl Inclaor2.Lateral Inclaor3.Crnlne lcucptdl{.ftrrt Prcml* {tlrrt blcurpfuilS.Secord Prmlrr lrssoad Disupidl6.first lblar?.8acond lhlarl.ltird l3olar {rlsdm toothf&orer festi9.!tird &lat {rl*do0 tootDl10.$*ond liolarll.flrot lhlarl2.Srcond Pruolrr lrceond blcnrpirtll3.Firrt Pnaolrr lfint btcurpidl1l.Gratuu (euspidllf.latrral Inciaorlf.Gsrtral lacisor

Finding:r Missing Teeth:

L. Dental Caries, Cavities or Erosion: Left lower Third Molar.2. Dental Filling: Norrnal3. OralMucosa: Normal4. Gums: Normal

Treatment & Suggestion:Normal

Conclusion:Free from infections of teeth, tums and oral cavity {dentally fitl.

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