Cs Form No.

211 (1997)
MEDICAL CERTIFICATE PHILIPPINE CIVIL SERVICE
For Employment

INSTRUCTION
1.This medical certificate should accomplished by a government physician.
2.Attached this certificate to appointments that are initial, original or reinstate, enrollment /reemployment.

FOR THE PROPOSED APPOINTEE

NAME ( Last ,Middle if Married Women, Maiden Name) Agency

ADDRESS: PROPOSED POSITION

AGE SEX CIVIL STATUS

Pre -Employment Medical -Physical Test

1. Blood Test
2. Urinalysis
3. Chest X-Ray
4. Drug Test
5. Neuro Psychiatric Examination ( If necessary)

NOT : ALL RESULTS OF EXAMINATION MUST BE ATTACHED TO THIS FORM

FOR THE PHYSICIAN

I HEREBY certify that I personally examined the above – named individuals and
Found her/him to be physically and mentally fit/unfit for enrollment/employment.
Signature of Physician Certificate No. Other Information about Appointee

Official Designation Height Weight

(Barefoot) (stripped)

Agency Date Examined