Scribd
Upload
29 views1 page

Mindoro State University

Uploaded by

Julie Ann Magsino
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
29 views1 page

Mindoro State University

Uploaded by

Julie Ann Magsino
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 1

Republic of the Philippines FM-CLINIC-02

Revision : 1
MINDORO STATE UNIVERSITY r
Calapan City Campus
Masipit, Calapan City, Oriental Mindoro
Tel/Fax 043-285-2368

MEDICAL EXAMINATION Normal Findings


REPORT
Head/Scalp
( ) PRE-EMPLOYMENT ( ) 1x1 photo
ANNUAL ( ) OJT Eyes
Ears
PERSONAL DATA Nose/Sinuses
Name : Mouth/Throat
Age/Sex : Civil Status: Neck/Thyroid
Address : Course/Major
Chest/Breast
Date of Examination :
Lungs
MEDICAL HISTORY Heart
A. Present Symptoms ___________________________ Abdomen
B. Past Medical Hx ___________________________ Back
C. Family Medical Hx ___________________________ Anus
D. Operations ___________________________ Genitals
E. Allergies ___________________________ Extremities
F. OB/Menstrual Hx ______________G P( )
LMP _______Duration_______ Interval________ Skin
G. Personal/Social Hx ___________________________

PHYSICAL EXAMINATION
A. Blood Pressure ____________mmHg
B. Pulse Rate ____________beats per Minute
C. Vision __________________________
D. Hearing __________________________
E. Weight __________________________
F. Height _______ft. __________ in.
G. Temperature __________________________
DENTAL EXAMINATION

[ ] Oral Prophylaxis ____________ [ ] Extraction______________


[ ] Fillings______________ [ ] Others_________________

_______________________
GLADYS M. RALLETA, D.M.D.
License Number: 35431
School Dentist

LABORATORY
A. Complete Blood Count ( ) Normal ( ) Findings ____________________
B. Urinalysis ( ) Normal ( ) Findings ____________________
C. Fecalysis ( ) Normal ( ) Findings ____________________
D. Hepatitis B sAg ( ) Normal ( ) Findings ____________________
E. Hepatitis A screening ( ) Normal ( ) Findings ____________________
F. Pregnancy test ( ) Normal ( ) Findings ____________________
G. Psychological Evaluation ( ) Normal ( ) Findings ____________________
H. chest X-ray ( ) Normal Chest ( ) Findings ____________________
I. Electrocardiography (ECG) ( ) Normal ( ) Findings ____________________

CERTIFICATION CLASSIFICATION

“I Certify that I am the same ( ) CLASS A Physically fit for all types of work. No defects noted.
Person being medically examined whose ( ) CLASS B Physically for all types of work. Has minor defects or
name and picture appears on this medical ailment that is easily curable and offers no handicap
record and that I have truthfully answered to job applied for.
all the questions asked regarding my well- ( ) CLASS C Employment at the risk and discretion of management.
being.” ( ) Pending __________________________________________
( ) UNFIT __________________________________________
REMARKS __________________________________________
__________________________________________
______________________________ __________________________________________
Student’s Signature Over Printed Name

__________________________
CORALYN V. BAUTISTA, M. D.
License Number: 75872
School Physician

You might also like