Employee Health Assessment

Personal Data

First Name *

Last Name

Date of Birth *

Gender *

Pregnant

How many weeks pregnant (If yes)

Height (cm)

Weight (kg)

Waist (cm)

Marital Status

Job

Address

Personal Medical History (1/3)

How would you describe your overall health?

Excellent

Good

Fair

Poor

Do you have any allergies?

Yes

Not Sure

Medications Allergy

Food Allergy

Environmental Allergy (e.g., dust, pollen)

Personal Medical History (2/3)

Have you ever had surgery or been hospitalized?

Yes

Surgeries/Hospitalizations details

Are you currently taking any medications or supplements on a regular basis?

Yes

Medications and Supplements details

Have you ever consulted a doctor about your health condition?

Yes

Last time visit

Last Medical Check-Up

When was your last general medical check-up

Blood Test

Hemoglobin (g/dL)

White Blood Cell (/µL)

Platelets (/µL)

Fasting Blood Glucose (mg/dL)

HbA1c (%)

Total Cholesterol (mg/dL)

LDL Cholesterol (mg/dL)

HDL Cholesterol (mg/dL)

Triglycerides (mg/dL)

Creatinine (mg/dL)

Uric Acid (mg/dL)

SGPT (U/L)

SGOT (U/L)

Vital Signs

Blood Pressure

Sistole (mmHg)

Diastole (mmHg)

Heart Rate (bpm)

Respiratory Rate (breaths/min)

Body Temperature (℃)

Oxygen Saturation (%)

Immunization/Vaccination History

Are your vaccinations up to date

Yes

Not Sure

Lifestyle and Habits (1/2)

Daily Water Intake (Liter)

Tobacco and Nicotine

Consuming tobacco and nicotine

Never

Former

Currently

When did you quit smoking? (years ago)

How long did you smoke before quitting? (years)

Cigarettes per day

How long have you been smoking? (years)

Other nicotine products

Vaping

Chewing Tobacco

Heated Tobacco

None

Alcohol

Consuming alcohol

Never

Former

Currently

When did you quit drinking? (years ago)

How long did you drink before quitting? (years)

Type of alcohol

Beer

Wine

Spirits (Vodka, Whiskey, etc.)

How long have you been drinking alcohol? (years)

How often do you have an alcohol

On a typical day when you drink, how many drinks do you have? (average)

Beer → 330ml = 1 drink ; Wine → 100-150ml = 1 drink ; Spirits → 1 shot (30-40ml) = 1 drink

Physical Activity

Active days per week

On average, how many minutes do you spend while doing physical activity per active day

On average, how many hours do you spend sitting or being sedentary per day

Type of physical activities do you usually engage

Lifestyle and Habits (2/2)

Diet Pattern

How many servings of fruits and vegetables do you consume daily?

1 serving ≈ 80-100g Fruits or Vegies / 150ml juice without sugar

Sugar-sweetened beverages per day

1 serving ≈ 240ml / 8oz

Frequency of highly processed or fast food

Dietary pattern

Please specify other dietary pattern

Sleep

Average sleep hours per night

Sleep quality in last 2 week (1 - 5)

Snoring or witnessed apnea

Yes

Not Sure

Stress and Mental Well-Being

On a scale 0 - 10, how stressed are you right now?

Environment and Living Conditions

What type of area do you currently live in?

How often are you exposed to air pollutants? (e.g., vehicle exhaust, factory smoke, cigarette smoke, burning garbage)

How Often do You Experience the Following? (1/4)

Feeling of fatigue or weakness (Merasa lelah atau lemas)

Never

Rarely

Sometimes

Often

Shortness of breath (Sesak napas)

Never

Rarely

Sometimes

Often

Palpitations (Jantung berdebar cepat)

Never

Rarely

Sometimes

Often

Sensitivity to cold (Sensitif terhadap udara dingin)

Never

Rarely

Sometimes

Often

Chest pain (Nyeri dada)

Never

Rarely

Sometimes

Often

Swelling at the base of the neck (Pembengkakan di pangkal leher)

Never

Rarely

Sometimes

Often

Difficulty passing stool (Susah Buang Air Besar)

Never

Rarely

Sometimes

Often

Passing Very Little or No Urine Daily (Produksi Urin Sangat Sedikit atau Tidak Ada)

Never

Rarely

Sometimes

Often

Blood in urine (Kencing berdarah)

Never

Rarely

Sometimes

Often

How Often do You Experience the Following? (2/4)

Bleeding / bruising easily (Mudah berdarah atau memar)

Never

Rarely

Sometimes

Often

Mood swings or depression (Perubahan suasana hati atau depresi)

Never

Rarely

Sometimes

Often

Sudden severe headache (Sakit kepala hebat yang muncul secara mendadak)

Never

Rarely

Sometimes

Often

Difficulty sleeping at night (Kesulitan tidur di malam hari)

Never

Rarely

Sometimes

Often

Unexpected weight gain (Kenaikan berat badan secara tiba-tiba)

Never

Rarely

Sometimes

Often

Unexpected weight loss (Penurunan berat badan secara tiba-tiba)

Never

Rarely

Sometimes

Often

Sleepiness (Mudah mengantuk)

Never

Rarely

Sometimes

Often

Swollen ankles, feet, or hands (Pembengkakan pada pergelangan kaki, kaki, atau tangan)

Never

Rarely

Sometimes

Often

Redness in the hands (Kemerahan pada tangan)

Never

Rarely

Sometimes

Often

Red spots on the skin (Bintik merah pada kulit)

Never

Rarely

Sometimes

Often

How Often do You Experience the Following? (3/4)

Loss of appetite (Kehilangan nafsu makan)

Never

Rarely

Sometimes

Often

Cold hands and feet (Tangan dan kaki terasa dingin)

Never

Rarely

Sometimes

Often

Nausea or vomiting (Mual atau muntah)

Never

Rarely

Sometimes

Often

Coughing or wheezing (Batuk atau mengi)

Never

Rarely

Sometimes

Often

Memory loss (Kehilangan ingatan)

Never

Rarely

Sometimes

Often

Muscle cramps (Kram otot)

Never

Rarely

Sometimes

Often

Swelling of the abdomen (Pembengkakan pada perut)

Never

Rarely

Sometimes

Often

Increased frequency of urination, especially at night (Sering buang air kecil, khususnya pada malam hari)

Never

Rarely

Sometimes

Often

Excessive perspiration (Keringat berlebihan)

Never

Rarely

Sometimes

Often

Hair loss (Rambut rontok)

Never

Rarely

Sometimes

Often

How Often do You Experience the Following? (4/4)

Sudden loss of balance or coordination (Kehilangan keseimbangan atau koordinasi secara mendadak)

Never

Rarely

Sometimes

Often

Frequent falling (Sering terjatuh)

Never

Rarely

Sometimes

Often

Ringing in the ears (Denging di telinga)

Never

Rarely

Sometimes

Often

Weakness, numbness or tingling sensation in hands or feet (Kelemahan, mati rasa, atau sensasi kesemutan pada tangan atau kaki)

Never

Rarely

Sometimes

Often

Ulcers (Luka borok)

Never

Rarely

Sometimes

Often

Thrush (Sariawan jamur)

Never

Rarely

Sometimes

Often

Dry eyes (Mata kering)

Never

Rarely

Sometimes

Often

Sores, bumps, or blisters on certain parts of the body (Luka, benjolan, atau lepuh pada bagian tubuh tertentu)

Never

Rarely

Sometimes

Often

Uncontrolled movements while sleeping (Gerakan yang tidak terkontrol saat tidur)

Never

Rarely

Sometimes

Often

Heartburn (Rasa panas di dada)

Never

Rarely

Sometimes

Often

Family Medical History

Has anyone in your immediate family (Parents, Siblings, Children) been diagnosed with any of the following conditions?

Cancer Type

Mental Health Type

Mental and Social Health

Over the past two weeks, how often have you felt little interest or pleasure in doing things?

Not at All

Several Days

More than Half the Days

Nearly Every Day

Over the past two weeks, how often have you felt down, depressed, or hopeless?

Not at All

Several Days

More than Half the Days

Nearly Every Day

Over the past two weeks, how often have you felt nervous, anxious, or on edge?

Not at All

Several Days

More than Half the Days

Nearly Every Day

Do you have people you can rely on for emotional or practical support

Yes, Always

Sometimes

Rarely

No One

How would you describe your current workload or job-related stress?

Low

Moderate

High

Very High

Others

Do you have a preference for hospital location?

Local

Overseas

Are you covered by any health insurance?

Yes

Please specify the type of insurance?

Corporate

Personal

Both

Are you covered by any life/critical insurance?

Yes

Consent and Privacy

I confirm that the information provided in this form is true and accurate to the best of my knowledge*

I understand that my data may be securely processed by GrasiaCare's systems, including AI tools, for health assessment and personalized recommendations*

I agree to be contacted by GrasiaCare through my preferred communication channel for follow-up or clarification regarding this assessment (optional)

Personal Data

Personal Medical History (1/3)

Personal Medical History (2/3)

Personal Medical History (3/3)

Last Medical Check-Up

Blood Test

Vital Signs

Blood Pressure

Immunization/Vaccination History

Lifestyle and Habits (1/2)

Caffeine

Tobacco and Nicotine

Alcohol

Physical Activity

Lifestyle and Habits (2/2)

Diet Pattern

Sleep

Stress and Mental Well-Being

Environment and Living Conditions

How Often do You Experience the Following? (1/4)

How Often do You Experience the Following? (2/4)

How Often do You Experience the Following? (3/4)

How Often do You Experience the Following? (4/4)

Family Medical History

Mental and Social Health

Others

Consent and Privacy