PNP HS MS FORM NO.

2012 -02
Republic of the Philippines
NATIONAL POLICE COMMISSION
PHILIPPINE NATIONAL POLICE

REGIONAL HEALTH SERVICE 4A

Camp Vicente Urn, Barangay Mayapa, Calamba City, Laguna

PHYSICAL EXAMINATION REPORT

LAST NAME

SEX

WEIGHT (kg) stripped

HEIGHT (cm) barefoot

NEXT OF KIN (NAME, RELATIONSHIP, ADDRESS, CONTACT NO.)

PLACE OF BIRTH

DATE OF BIRTH (mm/dd/yy)

COLOR OF HAIR

P4YICAI. EtfAL.UATI ON.

Check each Item in appropriate column.

2.

RESPIRATORY RATE
(cpm)

NORMAL

ABNORMAL

TEMP (C)

I I
I I
I
I I

'18.5
L5-22.5
23.24.9
25-29.9
'30

525W51641
NORMAL
OVERWE6j1
OBESE
OBESE I

NOTE: Describe every abnormality In detail. Enter number of

pertinent item, before each comment. Use additional sheet if necessary.

XAMINSWS NETEALS

SKIN,LYMPHATICS
(identifying_body _marks, _scars _&_tattoos)
HEAD,FACE, AND SCALP

NECK_(mass,_lymph_nodes)
3.
4.
NOSE
S.MOUTHAND THROAT
6.
EARS-GENERAL (i n t._& ext)
7.
EAR_DRUMS (perforation)
B.
HEARING (WHISPER VOICE TEST)
RIGHT WV_..._.J1S_ LEFT _WV__._.J_15
9.
EYES_(general _appearance)
10. PUPILS_(size,_reactIons),_VISUAL_FIELD
11. OCULAR MOTILITY (EOM)
12. DISTANT VISION
RIGHT_ / PINHOLE_I
LEFT J
PINHOLE .J_
13. NEAR VISION
LEFT_J
RIGHT _J__.
14. COLOR VISIOFI(ISHIHAPA)
15. LUNGS AND CHEST (include _breasts)
16. HEART (PMI,_rhythm, _murmur)
17. PERIPHERAL VASCULAR (varicosities)
18. ABDOMEN (note for hernia)
ANUS AND RECTUM
19.
20. UPPER_EXTREMITIES _(strength,_range of motion)
21. LOWER_EXTREMITIES _(strength,_range_of motion)
22. SPINE, MUSCULOSKELETAL
23. NEUROLOGIC
ffiUS ONLY (check how done)
24. PELVIC
IVAGINAL
( (RECTAL

26. OBSTETRIC SCORE

G__P_(_ - - ._J
LMP

HOT

NOB

RBC

URINALYSiS
SP. GRAVITY

ALBUMIN

( (NSD
( )ABORTION

I )C/S

_________________
ECG (PLACE, DATE, INTERPRETATION)

CXRAY (PLACE, DATE, FILM NUMBER, RESULT)

CASTS

BMI (weight in kg / height in meter

squared):

WAIST CIRCUMFERENCE

rd

1.

COLOR OF EYES

HEART PATE (bpm)

BLOOD PRESSURE (mmHg)/DATE

r,.
ST

DATE OF EXAMINATION

UNIT ASSIGNMENT/ADDRESS

LENGTH OF SERVICE

CIVIL STATUS

BADGENO.

RANK

PURPOSE OF EXAMINATION

PERMANENT HOME ADDRESS (NO., STREET, CITY OR TOWN PROVINCE)

AGE

CONTROL NO.:

QUALIFIER

MIDDLE NAME

FIRST NAME

wc

OIFF.CT

rBLOOD TYPE )ABOJRN)

18$

CREA

IBUN

__________________________ SEROLOGY
SUGAR
MICROSCOPIC
HBsAg

RPR

HIVTEST

OTHERS
CONSISTENCY

COLOR

OVA /PARASITE

OTHERS

OTHER TESTS/ANCILLARY PROCEDURES:

ADDITIONAL CLINICAL NOTES:

SUMMARY OF DEFECTS NOTED/DIAGNOSIS (basis for disqualification):

U

RECOMMENDATIONS:
PHYSICALLY FIT FOR POUCE SERVICE
MEDICALLY FIT FOR POLICE SERVICE WITH RESTRICTIONS, specify;_____________________
TEMPORARILY DEFERRED FOR POLICE SERVICE FOR
MONTHS
MEDICALLY UNFIT FOR POLICE SERVICE

iTIJ:
PRC*RX

I hereby certify that ihave seen and thoroughly examined this applicant together with his/her laboratory results that lead to the above recommendation/s.

SIGNATURE OVER PRINTED NAME

PE MEDICAL OFFICER

DATE EVALUATED

Republic of the Philippines

NATIONAL POLICE COMMISSION
Philippine National Police
REGIONAL HEALTH SERVICE 4A
Camp Vicente Lim, Barangay Mayapa, Calamba City, Laguna

MEDICAL HISTORY REPORT

Medical Prescreen Questionnaire

2x2 colored picture with white

background and the name should
appear below the picture
(LAST, FIRST, M.I.)

PICTURE SHOULD BE
WITHOUT HEADGEAR,
MOUSTACHE, EYE GLASSES OR
SUN GLASSES.

CONTROL NO:

DATE:
LAST NAME

CONTACT NUMBER

PERMANENT HOME ADDRESS (NUMBER,STREET,CITYOR TOWN PROVINCE)

DATE OF BIRTH

PURPOSE OF EXAMINATION

RELIGION

PLACE OF BIRTH

CIVIL STATUS

SEX

QUALIFIER AGE

MIDDLE NAME

FIRST NAME

NEXT OF KIN (NAME, RELATIONSHIP, ADDRESS, CONTACT NO.)

INSTRUCTION: The instructions contained hereto and in the other medical forms are pertinent and vital. They shall be part of the personnel's medical records. The

information you will give shall constitute an official statement. They are to be filled-up properly, honestly and with outmost integrity. If you are
accepted into the PNP based on afalse statement herein you can be recommended for summary dismissal proceedings in the future.
STATE OF HEALTH
ff
deceased

Stable w/
NAME

1. FAMILY MEMBERS

DATE OF BIRTH

known

Seriously

medical

III

Irate

condition/s

a. FATHER'S NAME

b. MOTHER'S NAME

I c. SIBLINGS

d. SPOUSE'S NAME

I e. CHILDREN'S NAME

2. FAMILY MEDICAL HISTORY

a.

Have anyone in your family suffered from the following:

CONDITIONS

YES

NO

RELATIONSHIP

CONDITIONS

Diabetes

Hepatitis

Stroke

Kidney Disease

Heart Disease

Leukemia/Blood Cancers

High Blood Pressure

Bleeding Disorders

Asthma

Mental Disorder

Pulmonary Tuberculosis

Drinking Problem

Goiter/Thyroid Disease

Smoking Problem

b.

Do you have any family member who died of heart disease?

If YES, indicate relationship and age at the time of death

J YES

NO

YES

NO

RELATIONSHIP

4. WOMEN'S HEALTH HISTORY

3. PERSONAL SOCIAL HISTORY

No. of Pregnancies

Age at start of Menses:

stics_perdoy since________

No. of deliveries

REGULAR

UVES

UNO

when____________

No. of abortions

DYSMENORRHEA

J YES

J NO

No. of miscarriages

Menses interval

Menses Duration

Describe
Smoking

YES

Stopped Smoking
Alcohol

NO

x per month

Last Pap Smear:

Prohibited Drugs
Exercise

days

days

Last Mentrual Period (date)

when___________

Stopped Drinking Alcohol

Normal: thES

x per month

minis per day

iNO

Current Method of Contraception, If there's any:

Right-handed
Left-handed
Usual Physical Activities/Sports Played (how often)

S. VACCINATION HISTORY

Vaccine

YES

NO

When

No. of doses

Vaccine

Hepatitis A

Typhoid

Hepatitis B

Varicelia (Chicken pox)

Influenza (Flu)

Tetanus

Pneumonia

Measles, Mumps, Rubella

Others:

YES (NO

When

No. of doses

Others:

MEDICATION HISTORY

6.

b. Allergies to Medications, drugs or food, If there are any:

a. Current Medications you are taking if there are any

PAST MEDICAL HISTORY. HOSPITALIZATION & SURGERY (tt YES, please describe In the separate portion)

7.

Have you ever had or do you now have the following:

YES

NO

Have you ever had or do you now have the following-

- YES

NO

1.

Asthma. wheezing, or inhaler use

35.

Epilepsy, fits, seizures, or convulsions

2.

TuberculosIs

36.

SleepwalkIng

3.

Collapsed lung or other lung condition

37.

Fainting spells or passing out

4.

Pneumonia

38.

Bed wetting at age 12

S.

Whooping cough

39.

Heat Exhaustion

- -

- -

6.

Diptherfa

40.

Absence or disturbance of the sense of smell

7.

Anemia

4L

Recurrent nose bleeding

8.

Rheumatic Fever

42.

Detached retina or surgery for a detached retina

- -

9.

Malaria

43.

Wear contact lenses

- -

10.

Chicken Pox

44.

Night blindness

11.

Typhoid Fever

45.

Any other eye condition, injury or surgery

12.

Measles

46.

Double vision

13.

Mumps

47.

Perforated eardrum or tubes in eardrum/s

14.

Passing out of worms (parasitic infections)

48.

Recurrent ear infection

15.

Ulcer

49.

Frequent or severe headaches

- -

16.

Hepatitis A or B

SO.

Recurrent neck or back pain

- -

17. Jaundice (yellow discoloration of the skin and eyes)

18.

Anorexia or other eating disorders

19.

intestinal obstruction oc*edbowels)

20.

Gan bladder diseaseorgall stones

21.

Kidney Disease, including kidney stones

22.

Sexually-Transmitted Infections

23.

Recurrent Urinary Tract Infections

24.

Missing a kidney

25.

(Females only) Dysmenorthea

Si.

Arthritis or frequent joint pains

- -

52.

Fracture in any part of the body

- -

53.

Pain or swelling at the site of an old fracture

- -

Swelling of)oints

- -

55.

Lower extremity weakness

- -

56.

Paral ysis of any part of the body

- -

57.

Used any form of body support or braces

- -

58.

Donated blood

- -

59.

Received blood transfusion

- -

154.

26.

(Moles only) Missing a testicle, testicular implant, or

undescended testicle

27.

Goiter or thyroid disease or with thyroid medications

28.

High blood sugar

29.

High blood pressure or with

(diabetes) or with diabetes medications

hypertension medications

including abnormally rapid or slow

Irregular heartbeat,

30.

60. Eye surgery, including radial keratotomy, lens implant or

other eye surgery to improve your vision
61. Ear surgery, to include repair of perforated ear drum,
hearing loss or need/use a hearing aid
62. Head injury, including skull fracture, resulting in
concussion, loss of consciousness, headaches, etc.
63. Dislocated joint, including knee, hip, shoulder, elbow,
64.

heart rates
Heart murmur, valve problem or mitral valve prolapse

31.

Discharged from military service for medical reasons

33. Been rejected for military service (temporary or

32.

- -

ankle or other joint

Broken bone requiring surgery to repair (w/or w/o pins,

- -

plates, screws or other metal fixation devices)

- -

intestine (other than

65.

Surgery to remove a portion of the

the appendix)

66.

Any illnesses, surgery, or hospitalization not listed above

- -

67. Evaluation, treatment, or hospitalization for alcohol abuse,

dependence, or addiction

permanent) for medical or other reasons

Seen a psychiatrist, psychologist, social worker, counselor
or other professional for any reason (inpatient or

34.

Evaluation, treatment, or hospitalization for substance use,

abuse, addiction or dependence (including illegal drugs,
prescription medications)

- -

68.

outpatient)

Describe In detail every YES answer, Including how It was known, treatment done, etc.

S.

REVIEW OF SYSTEMS
Have YOU had problems with any of the following within the past year?

GENERAL

Yes

LUNGS

No

WeightLoss or Gain

Coughing Up Blood

Fever

Shortness of Breath

Chronic Fatigue

Chronic Cough

Excessive

Bleeding

Yes

- - IncompleteUrination

PainfulBreathing

Increased Appetite

Wheezing

Increased Thirst

CARDIOVASCULAR

Excessive Sweating

Yes

No

Headaches

- -

Bloody Urine

- - Frequent Urination

- -

Nighttime Urination
Yes

No

Discharges:PenisfVagina

Unusual VaginalBleeding

Irregular Heart Beat

NEUROLOGIC

No

Yes

No

- -

Dizziness

- - Painful Urination

Chest Pain/Discomfort

EYES, EARS, NOSE

Yes

Loss of Urine

Blood Clot in Lungs

EasyBruising

GENITOURINARY

No

Seizures

- -

Numbness

- -

MemoryLoss

- -

Fainting Spells

Loss of coordination

MENSTRUAL PROBLEMS

Sexual Function Problems

- Yes

No

Itchy, Red Eyes

Palpitations

Vision Problems

Ankle/Hand Swelling

Muscle Weakness

Heavy

Bleeding

Frequent Colds

Legpainonwalking

Muscle Pain

Too Frequent Periods

GASTROINTESTINAL

Nasal Congestion

MUSKULOSKELETA.L

Tremors

- -

Yes

No

Yes

No

Cramps/Pain

Bleeding Between

Joint Pains

Periods

Ear Pain

Frequent Diarrhea

Joint Swelling

Ringing in Ears

Constipation

Clot inLeg Vein/LegPain

Hearing Loss

Blood in the Stools

Varicosities

Breast Pain

Sinus Problems

Nausea/Vomiting

Low Back Pain

Breast Lump

Nose

Bleeds

Hemorrhoids

THROAT

Yes

Sore Throat

No

Trouble swallowing

SKIN

Yes

NippleDischarge

EMOTiONAL

Yes

Bloating

Rash

ExcessiveWorrying

Oily Skin

Depression

Change in bowel movement

No

- -

Acne

Heartbum/Reflux

Dental Problems

BREAST PROBLEMS

Abdominal pain

I indigestion

Mouth Sores

--

Missed Periods

Dry Skin

Problems with sleep

Change in Mole characteristic

Serious Thoughts of
harming yourself or
others

No

- -

CERTIFY that the above information are true and correct to the best of my knowledge. I understand that failure to disclose pertinent personal medical
officer to my physical fitness to perform my duties and functions.
I hold myself liable for perjury, falsehood, misrepresentation or omission, or act of dishonesty, if there is willful failure to disclose pertinent medical
information. I attest to the truthfulness of this undertaking and submit to the legal and administrative consequences thereof if ever the statements above are wanting
I

information may affect the assessment and evaluation of any medical

in truth and substance.

Date

Signature Over Printed Name

Applicant
EVALUATOR:

Signature Over Printed Name

MEDICAL OFFICER