Republic of the Philippines

Department of the Interior and Local Government

BUREAU OF JAIL MANAGEMENT AND PENOLOGY
REGIONAL HEADQUARTERS VIII
Brgy. Guindapunan Palo, Leyte

INITIAL MEDICAL EVALUATION FORM for JO1 Attach

Applicants Passport Size
Picture
NAME: (LN,FN,MN)
HOME ADDRESS:
CONTACT #: DATE OF BIRTH: (MM/DD/YYYY)

PLACE OF BIRTH: AGE:

CIVIL STATUS: GENDER:
EDUCATION: ELIGIBILITY:

Requested by:
Applicant’s Signature C, PRM

To be filled-up by Health Service Unit

REMARKS
HEIGHT in meters
WEIGHT in kilograms
Name and Signature of
Body Mass Index (BMI) Health Personnel

INITIAL PHYSICAL EXAMINATIONS:

YES NO REMARKS
1. No gross/major visual defect
2. No hearing loss or impairment
3. No gross deformities of nasal and oropharyngeal
cavities
4. No gross deformities that may affect speech,
mastication and deglution
5. No gross skeletal deformity that will limit joint
movement
6. No dermatologic disease that are communicable
7. No skin tattoo/s and soft tissue and glandular
masses
8. No unusual body piercing/s

HEPATITIS B SCREENING: __________________________________

The undersigned hereby certifies that Mr/Ms __________________________, have

PASSED / FAILED the initial medical evaluation and is RECOMMENDED / NOT
RECOMMENDED to proceed to the next phase of the recruitment process.

J/SINSP TADEO P SAN GABRIEL, MD

Name and Signature of Health Officer