PNP HS FORM NO.

2014-05

2x2 colored picture with white

background and the name should
appear below the picture
Republic of the Philippines
National Police Commission
PHILIPPINE NATIONAL POLICE (LAST, FIRST, M.I. & BELOW IS THE
HEALTH SERVICE RANK).

Camp PBGen Rafael T Crame, Quezon City

CONTROL NO.___________________________________________

PE ROUTING SLIP AND INSTRUCTIONS

NAME: CEDRICK PINEDA PICONES AGE/SEX:________________

ADDRESS: ________________________________________________________ CONTACT #: _________________

ÿ NEW APPLICANT
ÿ OLD APPLICANT: Date/Place of Last Application: ______________ __________________ No of Application: ________

______________________________________
Signature Over Printed Name of Applicant

a. Get the appropriate form for the desired examination

1ST STEP b. Fill up Medical History Form and other PE forms completely
c. Read instructions carefully
MEASUREMENTS DATE EXAMINER’S INITIAL

HEIGHT

WEIGHT
2ND STEP
WAISTLINE

BMI

BP

3RD STEP HEART RATE

RESPIRATORY RATE

4TH STEP GENERAL PHYSICAL EXAMINATION

With deficiency No deficiency
5TH STEP EAR EXAMINATION
Visual Acuity
Right Left
6TH STEP EYE EXAMINATION Snellen

7TH STEP EYE EXAMINATION Color Vision (Ishihara)

With deficiency No deficiency
8TH STEP DENTAL EXAMINATION

9TH STEP LABORATORY & X-RAY

10TH STEP ECG

REVIEW OF MEDICAL HISTORY, EVALUATION OF LAB, ECG AND

11TH STEP CXR RESULTS

12th STEP FINAL EVALUATION BY CHIEF MEDICAL DISPENSARY

Signature

1CY2023_2023_AADZWT