PNP HS MS FORM NO.

2012-01
2x2 colored picture with white
background and the name should
e Philippines appear below the picture
POLICE COMMISSION (LAST, FIRST, M.I.)
nal Police
CE
Quezon City
PICTURE SHOULD BE
WITHOUT HEADGEAR,
MEDICAL HISTORY REPORT MOUSTACHE, EYE GLASSES OR
Medical Prescreen Questionnaire SUN GLASSES.

DATE:
CONTROL NO.
LAST NAME FIRST NAME MIDDLE NAME QUALIFIER AGE SEX CIVIL STATUS

PERMANENT HOME ADDRESS (NUMBER,STREET,CITY OR TOWN PROVINCE) CONTACT NUMBER

DATE OF BIRTH PLACE OF BIRTH RELIGION PURPOSE OF EXAMINATION

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 a false statement herein you can be recommended for summary dismissal proceedings in the future.
PLEASE CHECK AND WRITE YOUR ANSWERS ON THIS QUESTIONNAIRE ON THE SPACE PROVIDED, may use additional sheet/s if necessary.
STATE OF HEALTH
Stable w/
known If deceased
1. FAMILY MEMBERS NAME DATE OF BIRTH Seriously
Good please indicate
medical ill
cause of death
condition/s

a. FATHER’S NAME

b. MOTHER’S NAME

c. SIBLINGS

d. SPOUSE’S NAME

e. CHILDREN’S NAME

2. FAMILY MEDICAL HISTORY

a. Have anyone in your family suffered from the following:
 CONDITIONS YES NO RELATIONSHIP CONDITIONS YES NO RELATIONSHIP
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? ‫ ڤ‬YES ‫ ڤ‬NO
If YES, indicate relationship and age at the time of death ______________________________________________________________________

3. PERSONAL SOCIAL HISTORY

4. WOMEN’S HEALTH HISTORY
Describe YES NO No. of Pregnancies Age at start of Menses:
Smoking sticks ______per day since_________ No. of deliveries REGULAR ‫ ڤ‬YES ‫ڤ‬NO
Stopped Smoking when__________________ DYSMENORRHE
No. of abortions A ‫ ڤ‬YES ‫ڤ‬NO
Alcohol ___________ x per month
No. of miscarriages Menses Interval Menses Duration
Stopped Drinking Alcohol when______________
Last Menstrual Period (date) _______ days _______ days
Prohibited Drugs
Last Pap Smear:
Exercise ______min/s per day ______x per month
Normal: ‫ ڤ‬YES ‫ ڤ‬NO
Right-handed
Current Method of Contraception, if there’s any:
Left-handed

Usual Physical Activities/Sports Played (how often)

5. VACCINATION HISTORY
Vaccine YES NO When No. of doses Vaccine YES NO When No. of doses
Hepatitis A Typhoid

Hepatitis B Varicella (Chicken pox)

Influenza (Flu) Tetanus

Measles, Mumps,
Pneumonia
Rubella
Others: Others:

6. MEDICATION HISTORY
a. Current Medications you are taking if there are any: b. Allergies to Medications, drugs or food, if there are any:
7. PAST MEDICAL HISTORY, HOSPITALIZATION & SURGERY ( ) If YES, please describe in the separate portion)
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, faints, 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
5. Whooping cough 39. Heat Exhaustion
6. Diphtheria 40. Absence or disturbance of the sense of smell
7. Anemia 41. 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 ear drum or tubes in ear drum/s
14. Passing out of worms (parasitic infections) 48. Recurrent ear infection
15. Ulcer 49. Frequent or severe headaches
16. Hepatitis A or B 50. Recurrent neck or back pain
17. Jaundice (yellow discoloration of the skin and eyes) 51. Arthritis or frequent joint pains
18. Anorexia or other eating disorders 52. Fracture in any part of the body
19. Intestinal obstruction (locked bowels) 53. Pain or swelling at the site of an old fracture
20. Gall bladder disease or gall stones 54. Swelling of joints
21. Kidney Disease, including kidney stones 55. Lower extremity weakness
22. Sexually-Transmitted Infections 56. Paralysis of any part of the body
23. Recurrent Urinary Tract Infections 57. Used any form of body support or braces
24. Missing a kidney 58. Donated blood
25. (Females only) Dysmenorrhea 59. Received blood transfusion
26. (Males only) Missing a testicle, testicular implant, or 60. Eye surgery, including radial keratotomy, lens implant
undescended testicle or other eye surgery to improve your vision
27. Goiter or thyroid disease or with thyroid medications 61. Ear surgery, to include repair of perforated ear drum,
hearing loss or need/use a hearing aid
28. High blood sugar (diabetes) or with diabetes 62. Head injury, including skull fracture, resulting in
medications concussion, loss of consciousness, headaches, etc.
29. High blood pressure or with hypertension medications 63. Dislocated joint, including knee, hip, shoulder, elbow,
ankle or other joint
30. Irregular heartbeat, including abnormally rapid or 64. Broken bone requiring surgery to repair (w/ or w/o
slow heart rates pins, plates, screws or other metal fixation devices)
31. Heart murmur, valve problem or mitral valve prolapse 65. Surgery to remove a portion of the intestine (other
than the appendix)
66. Any illnesses, surgery, or hospitalization not listed
32. Discharged from military service for medical reasons
above
33. Been rejected for military service (temporary or 67. Evaluation, treatment, or hospitalization for alcohol
permanent) for medical or other reasons abuse, dependence, or addiction
34. Seen a psychiatrist, psychologist, social worker, 68. Evaluation, treatment, or hospitalization for substance
counselor or other professional for any reason use, abuse, addiction or dependence (including
 (inpatient or outpatient) illegal drugs, prescription medications)
Describe in detail every YES answer, including how it was known, treatment done, etc.

8. REVIEW OF SYSTEMS
Have YOU had problems with any of the following within the past year?
GENERAL Yes No LUNGS Yes No GENITOURINARY Yes No NEUROLOGIC Yes No
Weight Loss or Gain Coughing Up Blood Incomplete Urination Headaches
Fever Shortness of Breath Loss of Urine Dizziness
Chronic Fatigue Chronic Cough Painful Urination Seizures
Excessive Bleeding Blood Clot in Lungs Bloody Urine Numbness
Easy Bruising Painful Breathing Frequent Urination Memory Loss
Increased Appetite Wheezing Night time Urination Fainting Spells
Increased Thirst CARDIOVASCULAR Yes No Discharges: Penis/Vagina Tremors
Excessive Sweating Chest Pain/Discomfort Unusual Vaginal Bleeding Loss of coordination
EYES, EARS, NOSE Yes No Irregular Heart Beat Sexual Function Problems MENSTRUAL PROBLEMS Yes No

Itchy, Red Eyes Palpitations MUSKULOSKELETAL Yes No Cramps/Pain

Vision Problems Ankle/Hand Swelling Muscle Weakness Heavy Bleeding
Frequent Colds Leg pain on walking Muscle Pain Too Frequent Periods
Nasal Congestion GASTROINTESTINAL Yes No Joint Pains Bleeding Between Periods
Ear Pain Frequent Diarrhea Joint Swelling Missed Periods
Ringing in Ears Constipation Clot in Leg Vein/Leg Pain BREAST PROBLEMS Yes No
Hearing Loss Blood in the Stools Varicosities Breast Pain
Sinus Problems Nausea/Vomiting Low Back Pain Breast Lump
Nose Bleeds Hemorrhoids SKIN Nipple Discharge
THROAT Yes No Abdominal pain Acne EMOTIONAL Yes No
Sore Throat Bloating Rash Excessive Worrying
Mouth Sores Indigestion Oily Skin Depression
Dental Problems Heartburn/Reflux Dry Skin Problems with sleep
Change in bowel Change in Mole Serious thoughts of harming
Trouble swallowing
movement characteristic yourself or others
 I certify that the above information are true and correct to the best of my knowledge. I understand that failure to disclose pertinent
personal medical information may affect the assessment and evaluation of any 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 in truth and substance.

_____________________ ___________________________________
Date Signature Over Printed Name
Applicant
EVALUATOR:

________________________________________
Signature Over Printed Name MEDICAL OFFICER

Republic of the Philippines

NATIONAL POLICE COMMISSION
 Philippine National Police
HEALTH SERVICE
Camp Rafael Crame, Quezon City

Physical Examination Guide for Annual Physical Examination (APE)

Rank/Name of Examinee:
________________________________________________________
Signature:
________________________________________________________
Office/Unit:
________________________________________________________
Date Issued:
________________________________________________________

1st Step Download the Medical Prescreen Questionnaire. Read the instructions carefully. Applicant
must fill up the Medical Prescreen Questionnaire and Physical Examination Guide for APE.

2nd Step Submit to PE Section the accomplished Medical Prescreen Questionnaire and Physical
Examination Guide for APE on your scheduled date of Annual Physical Examination (APE) for
registration purposes.

3rd Step Measurement of height, weight, waistline and taking of vital signs (BP, RR, PR, Temperature).

Date Examiners Initial Signature of Examinee

th
4 Step
Laboratory

5th Step 12 Lead ECG

6th Step Chest X – ray

7th Step EENT (Eyes, Ears, Nose and Throat Examinations)

8th Step Physical Examination and consolidation of results.

9th Step
Releasing of Final Results

PNP HS FORM NO. 2012-04 2x2 colored picture with

white background and
Philippines the name should appear
CE COMMISSION below the picture
Philippine National Police (LAST, FIRST , M.I. & BELOW
IS THE RANK).
 HEALTH SERVICE
Camp Crame, Quezon City

ANNUAL PHYSICAL EXAMINATION REPORT

DATE: CONTROL NO.

RANK LAST NAME FIRST NAME MIDDLE NAME QUALIFIER BADGE NO.

AGE SEX CIVIL STATUS UNIT ASSIGNMENT/ADDRESS

PERMAN ENT HOME ADDRESS (NUMBER,STREET,CITY OR TOWN PROVINCE) CONTACT NUMBER

DATE OF BIRTH PLACE OF BIRTH DATE ENTERED SVC LENGTH OF SVC PURPOSE OF EXAMINATION

NEXT OF K IN (NAME, RELATIONSHIP, ADDRESS, CONTACT NO.)

THIS PART IS TO BE FILLED UP BY MEDICAL STAFF/ MEDICAL OFFICER

COLOR OF HAIR COLOR OF EYES BLOOD TYPE IDENTIFYING MARKS (birthmarks, scars, mole, tattoo, etc)

HEIGHT (cm ) WEIGHT (kg) WAISTLINE (in) BP(mmHg) CAR (bpm) RR (cpm) TEMP (Co)

BMI (wt in FOR FEMALES: CXR (result) VISUAL

kg / ht in OBSTETRIC SCORE G ___P ___ ( __ __ ACUITY
m2): ( ) UNDERWEIGHT < 18.5 ECG (result) OD
__ __ )
( ) NORMAL 18.5-22.9
OS
( ) OVERWEIGHT 23-24.9 LMP ______________________ HBsAg (result)
( ) OBESE I 25-29.9 OU
( ) OBESE II > 30 MENARCHE_________________

 NSD  C/S ____x  ABORTION

PERTINENT PHYSICAL EXAMINATION FINDINGS:

FINAL DISPOSITION PHYSICAL HEALTH PROFILE

(Encircle)

P1 P3
P2 P4

__________________________________________________________
SIGNATURE OVER PRINTED NAME OF
EXAMINING MEDICAL OFFICER