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1. Personal Information: Employee's basic details including full name, passport number, nationality, date of birth, gender, and intended position in Indonesia

2. Company Information: Details of the employing company including company name, address, and contact information

3. Medical History Declaration: Self-declared medical history including past conditions, surgeries, medications, and family medical history

4. Physical Examination Results: Comprehensive physical examination findings including height, weight, blood pressure, heart rate, and general physical condition

5. Laboratory Test Results: Results of mandatory laboratory tests including blood tests, urinalysis, chest X-ray, and drug screening

6. Medical Professional's Assessment: Overall health evaluation and fitness-for-work assessment by the examining physician

7. Certification: Official declaration of results and fitness for work, including doctor's signature and medical facility stamps

1. Schedule A - Required Laboratory Tests: Detailed list of mandatory laboratory tests and acceptable ranges for results

2. Schedule B - Physical Examination Checklist: Comprehensive checklist of all physical examinations to be performed

3. Schedule C - Medical Facility Requirements: List of approved medical facilities and their requirements for conducting the examination

4. Appendix 1 - Declaration Forms: Standard declaration forms to be signed by the employee and examining physician

5. Appendix 2 - Medical History Questionnaire: Detailed questionnaire for capturing complete medical history