RUBEN C. BARTOLOME M.D.

CLINIC
SOUTH SYQUIA APTS. 2021 M.H. DEL PILAR STREET MALATE, MANILA TEL. NO: 521-3857 & 303-8572 TO 73 FAX.: 525-1156 Package: Name of Employer: Name of Applicant: Address: Psycho Control #: Phase 1 Date of Examination: LUZERN Juan dela Cruz 22-Apr-2012 Job Applied for: Date of Birth: Control #: Quantity Surveyor 25-Dec-70 Age: 39

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Dental Control #:

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Physical Exam Significant Medical History Accidetal Injuries Deformities, Physical Defects: Allergies & Idiosyncrasies: Close contact with Tuberculosis: General Appearance: Head: Height Weight Ideal height: Blood Pressure: Eyes: Visual Acuity Pupilary reflexes Other findings: Ears: Auditory Acuity Nose & Throat Neck Heart & Circulation: Any evidence of impaired cardiac action Abdomen, Genitalia, Inguinal Region Any hernia? Anorectal: Extremeities & Spines Neurological Right Handes? Skin & Glands Arthritis Venereal Disease? Hemorrhoids, sinuses, fistulae? Low back pain Any abnormal reflexes Any tremors,incoordination weakness Edema, varicose veins, ulcers Personal & Family History of Mental Disease Left Right Teeth Trachea in midline Eardrums Speech Thorax Discharge Hoarseness Thyroid Enlarged left(without glasses) left(with glasses) Near vision Color Vision Temperature: right(with glasses) Are glasses necessary Ideal Weight: Respiration: Pulse: Cough or Expectoration: 1.5 x 1.5 Photo Control #:

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Laboratory PregnancyTest Blood Type Hemoglobin Hematocrit WBC RBC Platelets Sedimentation Rate Others: Defferential count Neutrophiles Segmenters Stab Cells Juveniles Myelocytes Myeloblasts Lymphocytes Lymphoblasts Monocytes Eosinophiles Basophiles X-RAY Control #: Feces Urine: 1.5 x 1.5 Photo Control #:

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Cashier Package: List of tests: 1.5 x 1.5 Photo Control #:

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