(PINK MED Medical & Diagnostic Center)

Main Branch Cabuyao Branch Calamba Branch Lipa Branch Mamatid Branch
Maharlika Hi-way. Brgy Sta. Anastacia 2nd Flr. Orofe Bldg. National Highway 2nd Flr. Magnav Bldg. National Highway 1270 Purok 4 Brgy. Bugtong na Pulo, 1270 Purok 4 Brgy. Bugtong na Pulo,
Sto. Tomas Batangas Brgy. Sala, Cabuyao, Laguna Brgy. Parian, Calamba Laguna Lipa City, Batangas Lipa City, Batangas
(047)788-3150 (049)304-3150 (049)304-3150 (049)304-3150

Number: MEDICAL EXAMINATION REPORT Date of Examination

049 [ ] PREEMPLOYMENT [ ] ANNUAL Thursday, June 30, 2022
PERSONAL DATA:
ERIC JAMES E. SIAPNO OMNIWORKS
Name :_____________________________________________________Company_________________________
Age :_____ MALE Civil Status: _________
30 Gender: __________ MARRIED Address: ____________________________________
BLK 19 LOT 2 SOUTVILLE 5 BRGY, TIMBAO
PHYSICAL EXAMINATION: BIÑAN LAGUNA
BMI _______________________________ Height: Feet: __________
5’4 Inch/es ________ Weight: __________kg.
50
120/70
Blood Pressure: ______________ mmHg 77
Pulse Rate:_______bpm Temperature______C
35.6
Ishihara: PASSED Near Vision: Far Vision: OD 20/20 OS 20/20
MEDICAL HISTORY ILLNESS / HOSPITALIZATIONS
OPERATIONS / ACCIDENTS
Anemia, High Blood Pressure HAS EXAMINEE SUFFERED FROM OR BEEN TOLD HE/SHE Skin Disease, Cancer
Allergy, Chest Pain, Diabetes HAS ANY OF THESE CONDITIONS? Persistent Back Pain
Heart Disease, Liver Disease Chronic Sinusitis
Asthma, Tuberculosis, Gastritis Congenital Disorder
Hernia, Goiter, Migraine Smoking
Kidney Disease Drinking
Normal Findings Normal Findings
[ ] Skin _____________________________ [ ] Heart ____________________________
[ ] Head/Scalp _____________________________ [ ] Abdomen ____________________________
[ ] Eye/External _____________________________ [ ] Back ____________________________
[ ] Nose _____________________________ [ ] Anus/Rectum ____________________________
[ ] Ears _____________________________ [ ] Genital Organs ____________________________
[ ] Neck/Thyroid _____________________________ [ ] Extremities ____________________________
[ ] Mouth/Throat _____________________________ [ ] Dental ____________________________
[ ] Chest/Breast _____________________________ [ ] LMP N/A
____________________________
[ ] Lungs _____________________________ [ ] OB History ____________________________
N/A
LABORATORY
Chest Xray [ ] Normal [ ] Findings ___________________________
Complete Blood Count [ ] Normal [ ] Findings ___________________________
Urinalisys [ ] Normal [ ] Findings ___________________________
Fecalysis [ ] Normal [ ] Findings ___________________________
Pregnancy Test [ ] Negative [ ] Findings ___________________________
N/A
Hepatitis A (Screening) [ ] Non-reactive [ ] N/A
Reactive __________________________
Hepatitis B (Screening) [ ] Non-reactive [ ] Reactive __________________________
N/A
ECG (12 Lead) [ ] Normal [ ] N/A
Findings ___________________________
Drug Test Methamphetamine (shabu) [ ] Negative [ ] Positive __________________________
Cannabinoids (Marijuana) [ ] Negative [ ] Positive __________________________
CERTIFICATION
I hereby allow PAC MED Medical & Diagnostic Center and the undersigned Physician to furnish such
Information as the company may need pertaining to my health status and other pertinent medical findings. Any
declaration I made however, contrary to my real health status forfeit my right to claim legal liabilities against the medical
clinic and examiner, and also will disqualify me from employment benefits and claims.
CLASSIFICATION:
[ ] CLASS A Physically Fit for all types of work. No physical defect noted.
[ ] CLASS B Physically Fit for all types of work. Has minor ailment/defect. Easily curable or offers no handicap.
[ ] CLASS C Employment at risk and discretion of management consider.
[ ] PENDING For further evaluation of ______________________________________________________________
Doctor’s Recommendations: _______________________________________________________________________________
______________________________________________________________________________________________________

ERIC JAMES E. SIAPNO

______________________________ June 30, 2022
_________________________ _____________________________
Signature Over Printed Name Date Medical Examiner
Applicant