PNP HS PE SECTION 2018-05

Republic of the Philippines

NATIONAL POLICE COMMISSION
PHILIPPINE NATIONAL POLICE
NATIONAL CAPITAL REGION POLICE OFFICE
REGIONAL MEDICAL & DENTAL UNIT
Camp Bagong Diwa, Bicutan, Taguig City

SPORTS/ PHYSICAL ACTIVITIES

MEDICAL EVALUATION FORM
DATE:_______________________ CONTROL NO.

RANK LAST NAME FIRST NAME MIDDLE NAME AGE SEX CIVIL
STATUS

UNIT/UNIT ADDRESS CONTACT NUMBER

DATE OF BIRTH BADGE NUMBER RELIGION PURPOSE OF EXAMINATION

NEXT OF KIN (NAME, RELATIONSHIP, ADDRESS, CONTACT NO.)

INSTRUCTION: The instructions contained hereto and in the other medical forms are pertinent and vital. They shall be part of the personnel’s medical records.
The information you will give shall constitute an official statement. They are to be filled-up properly, honestly and with outmost integrity. If you
are accepted into the PNP based on a false statement herein you can be recommended for summary dismissal proceedings in the future.
PLEASE CHECK AND WRITE YOUR ANSWERS ON THIS QUESTIONNAIRE ON THE SPACE PROVIDED may use additional sheet/s if necessary.

1. MEDICAL HISTORY: Do you have any of the following?

Yes No Yes No Yes No

‫ڤ‬ ‫ڤ‬ Diabetes ‫ڤ‬ ‫ڤ‬ Cancers ‫ڤ‬ ‫ڤ‬ Recent Surgery
‫ڤ‬ ‫ڤ‬ Heart Disease ‫ڤ‬ ‫ڤ‬ Leukemia/Bleeding disorders ‫ڤ‬ ‫ڤ‬ Recent Fracture
‫ڤ‬ ‫ڤ‬ High Blood Pressure ‫ڤ‬ ‫ڤ‬ Kidney Disease ‫ڤ‬ ‫ڤ‬ Recent Injuries
‫ڤ‬ ‫ڤ‬ Asthma/Lung Disease ‫ڤ‬ ‫ڤ‬ Liver Disease ‫ڤ‬ ‫ڤ‬ Pregnancy
‫ڤ‬ ‫ڤ‬ Goiter/Thyroid disease ‫ڤ‬ ‫ڤ‬ Recent Hospitalization (What, Where, When)

2. FAMILY MEDICAL HISTORY: Do you have any family member or relative who have any of the following?

Yes No CONDITIONS Yes No CONDITIONS Yes No CONDITIONS

‫ڤ‬ ‫ڤ‬ Diabetes ‫ڤ‬ ‫ڤ‬ Pulmonary Tuberculosis ‫ڤ‬ ‫ڤ‬ Goiter/Thyroid disease

‫ڤ‬ ‫ڤ‬ Heart Disease ‫ڤ‬ ‫ڤ‬ Hepatitis ‫ڤ‬ ‫ڤ‬ Cancer
‫ڤ‬ ‫ڤ‬ Hypertension ‫ڤ‬ ‫ڤ‬ Kidney Disease ‫ڤ‬ ‫ڤ‬ Bleeding Disorders
‫ڤ‬ ‫ڤ‬ Asthma/Lung Disease ‫ڤ‬ ‫ڤ‬ Liver Disease ‫ڤ‬ ‫ڤ‬ Mental Disorder

3. PERSONAL/SOCIAL HISTORY:
Yes No Yes No

Smoking sticks ______per day since_________ ‫ڤ‬ ‫ڤ‬ Alcohol ___________ x per month ‫ڤ‬ ‫ڤ‬

Stopped Smoking when__________________ ‫ڤ‬ ‫ڤ‬ Stopped Drinking Alcohol when______________ ‫ڤ‬ ‫ڤ‬

Usual Physical Activities/Sports Played (how often)

4. WOMEN’S HEALTH HISTORY: 5. MEDICATION AND ALLERGY HISTORY:

Last Menstrual Period: (date) a. Current Medications you are taking if there are any:
 6. PHYSICAL FITNESS TEST READINESS QUESTIONNAIRE. This questionnaire is being given to the participant before the any
physical or sports activity, this section may be used for legal and/or administrative purposes.
To be accomplished by the participant: Please read carefully and answer each one honestly: Check YES or NO.

YES NO
‫ڤ‬ ‫ڤ‬ 1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommend by a doctor?
‫ڤ‬ ‫ڤ‬ 2. Do you feel pain in your chest when you do physical activity?
‫ڤ‬ ‫ڤ‬ 3. In the past month, have you had chest pain even when you are not doing physical activity?
‫ڤ‬ ‫ڤ‬ 4. Do you experience shortness of breath or difficulty in breathing when doing physical activity?
‫ڤ‬ ‫ڤ‬ 5. Has any doctor ever said you have diabetes or increased blood sugar?
‫ڤ‬ ‫ڤ‬ 6. Have you had blood pressure over 140/90?
‫ڤ‬ ‫ڤ‬ 7. Do you lose balance because of dizziness or do you ever lose consciousness?
‫ڤ‬ ‫ڤ‬ 8. Do you have a bone or joint problem? For example knee or hip that could be made worse by a change in physical activity?
‫ڤ‬ ‫ڤ‬ 9. Have you had fever, cough, colds or even vehicular accident in the past week that required bed rest?
‫ڤ‬ ‫ڤ‬ 10. Do you know any other reason why you should not do any physical activity?

“I have read, understood and completed the questionnaire. I attest that the above information are true and correct to the best of my knowledge.”

_________________________________________________ DATE:_______________________
Name/Signature of PNP personnel

FOR MEDICAL OFFICERS

PNP BMI STANDARD (per age group)

BP PR HEIGHT WEIGHT BMI
 Severely underweight  Underweight
 Normal  Acceptable  Overweight
 Obese 1  Obese 2  Obese 3
6. PERTINENT PHYSICAL EXAMINATIONS: 7. ECG RESULT:

8. DIAGNOSIS / ASSESSMENT:

9. PLAN/RECOMMENDATION/S: 10. PHYSICAL

PROFILE

 FIT  UNFIT  DEFERRED - For the intended purpose stated above

FOR PFT PURPOSES

11. PFT REMARKS:  GO ____________________________  NO GO due to ___________________________________

 OBSTETRICALLY DEFERRED  FOR ALTERNATE PFT____________________________

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SEEN AND EVALUATED BY:

_______________________________________
Signature over printed name of Medical Office