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  • Sports Physical Activities Medical Evaluation Form

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    Ton Leidraj
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    Sports Physical Activities Medical Evaluation Form (2)

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    82 views2 pages

    Sports Physical Activities Medical Evaluation Form

    Uploaded by

    Ton Leidraj

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 2
    PNP HS PE SECTION 2018-05 of the Philippines NATIONAL POLICE COMMISSION PHILIPPINE NATIONAL POLICE 2x2 colored picture with NATIONAL CAPITAL REGION POLICE OFFICE een peer Gane REGIONAL MEDICAL & DENTAL UNIT eapiony ‘Camp Bagong Diwa, Bicutan, Taguig City (LAST, FIRST , M1. & SPORTS/ PHYSICAL ACTIVITIES MEDICAL EVALUATION FORM. BELOW IS THE RANK). DATE: ‘CONTROL No. RANK TAST NAME FIRST NAME, ‘MIDDLE NAME ‘AGE 30x evit STATUS ‘UNIT/UNTT ADDRESS ~ ‘CONTACT NUMBER DATE OF BIRTH ‘BADGE NUMBER RELIGION PURPOSE OF EXAMINATION TNEXT OF KIN (NAME, RELATIONSHIP, ADDRESS, CONTACT NO.) INSTRUCTION: The instructions contained hereto and inthe other medial forms are pertinent and vital. They shall be part ofthe personnes medea records. ‘The information you wil give shall constitute an official taterent. They are to be file-yp properly, honestly and wth outmost integrity. f you are accepted ito the PNP based on afoee statement herein you can be recommended fr summary dkmissol proceedings inthe future. PLEASE CHECK AND WRITE YOUR ANSWERS ON THIS QUESTIONNAIRE ON THE SPACE PROVIDED may use additional sheet/s if necessary. 1. MEDICALHISTORY: Do you have any of the following? Yes No Yes No Yes No S| diabetes 3a | Cancers SG | Recent surgery SS heart isease FS | Leukemia/Bleeding disorders | 3 | Recent Fracture _S_ [High Blood Pressure SS | Kidney disease FS _| Recent injuries <_< _[hathea/Lung Disease SS | Aner Disease S| Pregnancy FS [Goiterrthyroid disease FS _[ Recent Hospitalization (What, Where, When) 2. FAMILY MEDICAL HISTORY: Do you have any family member or relative who have any ofthe following? Yes No ‘CONDITIONS Yes No conpiions | Yes No CONDITIONS FS | Diabetes FS | Pulmonary Tuberculosis

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