20.1AttritionCY.

0007436
PNP HS FORM NO. 2014-04

Republic of the Philippines 2x2 colored picture with white

NATIONAL POLICE COMMISSION background and the name should
PHILIPPINE NATIONAL POLICE appear below the picture
HEALTH SERVICE (LAST, FIRST, M.I. & BELOW IS THE
Camp Rafael T Crame, Quezon City RANK).

FINAL PHYSICAL MEDICAL-DENTAL EXAMINATION REPORT

CONTROL NO.
RANK LAST NAME FIRST NAME MIDDLE NAME AGE/SEX CIVIL STATUS
DACUMOS MICHEAL JEREMY JUAN
UNIT ASSIGNMENT/ADDRESS CONTACT NUMBER

POSITION BADGE NO. DATE OF BIRTH PLACE OF BIRTH RELIGION

LENGTH OF SERVICE PERMANENT HOME ADDRESS (NUMBER, STREET, CITY OR TOWN PROVINCE)

NEXT OF KIN (Name, Relationship, Address, Contact No.)

DATE OF EXAMINATION PURPOSE OF EXAMINATION REQUESTING AUTHORITY

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 kg / FOR FEMALES: CXR (result) VISUAL ACUITY

ht in m2): ( ) UNDERWEIGHT < 18.5
OBSTETRIC SCORE G ___P ___ ( __ __ __ __ ) OD
( ) NORMAL 18.5-22.9
LMP ___________________ ECG (result) OS
( ) OVERWEIGHT 23-24.9 OU
( ) OBESE I 25-29.9  NSD  C/S ____x  ABORTION
HBsAg (result)
( ) OBESE II > 30 Color Vision

PERTINENT PHYSICAL EXAMINATION FINDINGS: FINAL DENTAL EXAMINATION FINDINGS:

DENTAL REMARKS:

AUTHORIZED DISPOSITION
EXAMINATION DATE REMARKS
SIGNATURE GRANTED NOT GRANTED
GENERAL MEDICAL EXAMINATION

NEURO-PSYCHIATRIC EXAM

DENTAL EXAMINATION

FINAL DISPOSITION
PHYSICAL HEALTH PROFILE
 RECOMMENDED (Encircle)
 NOT RECOMMENDED (State reason thereof): P1 P3
P2 P4

DATE: _______________________

____________________________________________________________
SIGNATURE OVER PRINTED NAME
C, MEDICAL-DENTAL BOARD