Ground Floor, Lagman-Garcia Bldg.

, Molino Road, Molino 3, Bacoor City, Cavite

(046) 516 7645 /0970-2186-355 / 0917-6818-948 Email: [email protected]
I hereby permit Doc Aid Diagnostic Center and the examining physician to furnish my employer such information pertaining to my health status and other pertinent
medical findings and do hereby release them from any and/or legal responsibility by doing so.

____________________________________________________ _____________________________________
Signature of Patient Date
PHYSICAL EXAMINATION REPORT
NAME: DATE OF BIRTH:
AGE:
LAST NAME FIRST NAME MIDDLE NAME GENDER:
ADDRESS: CONTACT NO.:
COMPANY: DATE OF EXAMINATION:
PERSONAL SOCIAL HISTORY:
( ) SMOKING ____________________ ( ) DRINKING ____________________ ( ) OTHERS ________________________
PAST MEDICAL HISTORY:
Asthma – Bronchial/skin Head/Neck Injury Others:
Cancer or Tumor Hypertension
Endocrine disorders (Diabetes Mellitus, Thyroid D/O) Kidney Disease (Polycystic, Lithiasis)
ENT disorders Liver Disease (Hepatic, Cirrhosis, etc.)
Genito Urinary (STD/UTI) Neurologic Disorder
Lung Disease (PTB, COPD) Viral Disorders
Medication/s Taken: Dosage: Frequency:

Operations: Immunizations:

Family History:

Menstrual History: LMP ___________ PMP ___________ Duration ___________ Interval: Regular Irregular
Obstetrical History: G _____ P ____ (___-___-___) NSD CS2 Complications
VITAL SIGNS Anthropometrics Visual Acuity
BP: 1st _____ 2nd _____ 3rd _____ Height _____cm BMI _____ Right: ______ Contact
PR: _____ RR: _____ Temp: _____ Weight _____kg IBW _____ Left: _______ Eyeglasses
PHYSICAL EXAMINATION
NORMAL FINDINGS
Skin ( ) _____________________________________________________________________________
Eyes: ( ) _____________________________________________________________________________
ENT: ( ) _____________________________________________________________________________
Neck: ( ) _____________________________________________________________________________
Chest/Lungs: ( ) _____________________________________________________________________________
Breast/Axilla: ( ) _____________________________________________________________________________
Heart: ( ) _____________________________________________________________________________
Abdomen: ( ) _____________________________________________________________________________
Back: ( ) _____________________________________________________________________________
Anus/Rectum: ( ) _____________________________________________________________________________
Genito-Urinary: ( ) _____________________________________________________________________________
Extremities: ( ) _____________________________________________________________________________
LABORATORY AND DIAGNOSTIC EXAMINATION
Complete Blood Count: ( ) _________________________________________________________________________________
Urinalysis: ( ) _________________________________________________________________________________
Fecalysis: ( ) _________________________________________________________________________________
Hepatitis B surface Ag: ( ) Non-Reactive ( ) Reactive _______________________________________________________
Chest X-ray: ( ) _________________________________________________________________________________
Drug Test: __________________________________________________________________________________________
ECG: __________________________________________________________________________________________
Others: __________________________________________________________________________________________

CLINICAL ASSESSMENT AND RECOMMENDATION:

( ) CLASS A Fit to work
( ) CLASS B Fit to work with minor ailment
( ) CLASS C May be employed after final clearance/treatment of: ________________________________________________________
( ) CLASS D May not be employed because of: ________________________________________________________________________
( ) PENDING ____________________________________________________________________________________________________
Doctor’s Recommendation:

Examining Physician: -_________________________________ License No.: _____________________