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    Annex 3 - Medcert

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    The medical certificate summarizes Gothel W. Bruha's medical history and current state of health. It notes she has a history of hypertension since 2011 and Paget's disease of the bone, which causes excessive bone formation. It also indicates she has coronary heart disease and is maintaining medications for both conditions, limiting her to light physical activity. Upon examination, she was found to have abnormal hearing and reflexes, high blood pressure, and disease of the cardiovascular and kidney systems. The physician confirms she is in a rather poor state of health without signs of infection.

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    Annex 3 - Medcert

    Uploaded by

    FC
    80 views3 pages
    The medical certificate summarizes Gothel W. Bruha's medical history and current state of health. It notes she has a history of hypertension since 2011 and Paget's disease of the bone, which causes excessive bone formation. It also indicates she has coronary heart disease and is maintaining medications for both conditions, limiting her to light physical activity. Upon examination, she was found to have abnormal hearing and reflexes, high blood pressure, and disease of the cardiovascular and kidney systems. The physician confirms she is in a rather poor state of health without signs of infection.

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    The medical certificate summarizes Gothel W. Bruha's medical history and current state of health. It notes she has a history of hypertension since 2011 and Paget's disease of the bone, which causes excessive bone formation. It also indicates she has coronary heart disease and is maintaining medications for both conditions, limiting her to light physical activity. Upon examination, she was found to have abnormal hearing and reflexes, high blood pressure, and disease of the cardiovascular and kidney systems. The physician confirms she is in a rather poor state of health without signs of infection.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    80 views3 pages

    Annex 3 - Medcert

    Uploaded by

    FC
    The medical certificate summarizes Gothel W. Bruha's medical history and current state of health. It notes she has a history of hypertension since 2011 and Paget's disease of the bone, which causes excessive bone formation. It also indicates she has coronary heart disease and is maintaining medications for both conditions, limiting her to light physical activity. Upon examination, she was found to have abnormal hearing and reflexes, high blood pressure, and disease of the cardiovascular and kidney systems. The physician confirms she is in a rather poor state of health without signs of infection.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 3

    Muntinlupa Public Hospital

    Civic Drive Filinvest Ave, Corporate Ave, Alabang, Muntinlupa, 1780 Metro Manila

    MEDICAL CERTIFICATE

    Name of Applicant: .......................................................................................................................


    Gothel W. Bruha

    Date of Birth: ................................................................................................................................


    November 1, 1951

    Past medical history (within five-year period before examination):


    TheThe above-mentioned
    patient is diagnose withpatient wasdisease.
    Paget’s sufferingexperience
    from hypertension sinceamount
    an excessive 2011 and there removal,
    of bone has beenfollowed
    no improvement on her illness.
    by more excessive bone
    Text
    Moreover,
    formation which our medical
    results records
    in larger show
    bones that
    being she was
    formed. admitted
    These new bonesto the
    mayhospital
    be soft on 2013 duewhich
    or deformed, to coronary heart
    can result disease,
    in pain until now
    and fracture.
    shetime,
    Over is maintaining medications
    the disease can for bothbones
    cause affected diseases, and which
    to become limits
    fragile and her body to light physical
    misshapen. Paget's activities
    disease of boneonly.
    most commonly occurs in
    the pelvis, skull, spine and legs. Thereby, limiting the patient’s mobility to light physical activities only.

    General Examination (mark with cross)

    Sight Hearing Teeth Heart Reflexes


    Normal x x

    Abnormal x x x

    BWR (Bordet-Wasserman Reaction): 138>110 FW: 150>125

    Blood Pressure: High EKG: 98<100 X-Ray Examination:

    Haematologic Values:
    Erythrocytes: 140<150 Leukocytes: 110>100 Count: 55

    Tests of Lever Function: ALT: µkat/l S-Glucose: mmol/l


    AST:
    ALP: S-Bilirubin: µmol/l

    Tests of Renal Function: Urea: mmol/l Na: mmol/l


    Creatinine: µmol/l K:
    Uric Acid: µmol/l Cl:

    Cholesterol: mmol/l

    Urine Analysis:
    Protein: 6.6 g/dl Sugar: 77.3 g/dl Urobilinogen: 28.8 IU/L

    Is applicant suffering from an infectious disease? No


    Viral:
    - Hepatitis:
    - Human Immunodeficiency Virus (HIV):

    Bacterial: No

    Mycotic: No

    Spirochetal: No
    Protozoan: No

    Metazoan: No

    Is applicant suffering from disease of?

    Skin, Connective Tissues or Bone: No


    Bronchopulmonary System: No
    Cardiovascular System: Yes
    Digestive System: No
    Kidneys: Yes
    Liver and Biliary Tract: No
    Blood and Blood-forming Organs: No
    Metabolism: No
    Endocrine System: No
    Nervous and Neuromuscular System: No

    Mental disorder: No
    Allergic disorder: No

    I confirm that the candidate is in (mark unequivocally):


    excellent, good, rather good, rather poor, bad state of health, without any symptoms of infection
    and I guarantee the accuracy of the information given above.

    Signature: ................................................ Physician/Affiliation ................................................


    Doo D. Little

    Address: ................................................
    Civic Drive, Filinvest Ave., Muntinlupa City Date: ................................................
    February 18, 2019

    To be signed by the applicant:

    The undersigned declares that he/she has answered the above questions truthfully and to
    the best of his/her ability.

    In accordance with the Czech regulations the applicant is required to pass general medical
    examination and blood tests in the Czech Republic.

    Applicant’s signature: .......................................

    Place: .............................................................. Date: ............................................................


    Certificate

    On the basis of a medical examination I certify that Mr./Mrs. ...................................................

    born on .......................................................................... is in good health.

    Date ...................... Doctor´s signature and stamp ..................................................................

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