PNP HS MS FORM NO.

2014-02 Revised 2017

Republic of the Philippines

National Police Commission
PHILIPPINE NATIONAL POLICE
HEALTH SERVICE
Camp PBGen Rafael T Crame, Quezon City

PHYSICAL EXAMINATION REPORT

DATE: _______________________ CONTROL NO. - - - - - - - - - - -
RANK LAST NAME FIRST NAME MIDDLE NAME AGE SEX CIVIL STATUS
PICONES CEDRICK PINEDA
PERMANENT HOME ADDRESS (NUMBER,STREET,CITY OR TOWN PROVINCE) CONTACT NUMBER

BADGE NO. DATE OF BIRTH PLACE OF BIRTH RELIGION PURPOSE OF EXAMINATION

LENGTH OF SERVICE UNIT ASSIGNMENT/ADDRESS

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

THIS PART IS TO BE FILLED-UP BY MEDICAL STAFF/MEDICAL OFFICER

HEIGHT (cm) barefoot WEIGHt (kg) stripped COLOR OF HAIR COLOR OF EYES WAIST CIRCUMFERENCE BMI (weight in kg / height in meter
squared):

BLOOD PRESSURE (mmHg) HEART RATE (bpm) RESPIRATORY

DATE DATE DATE DATE DATE DATE
RATE (cpm)

1ST 2nd 3 rd 1ST 2nd 3 rd TEMP (°C)

NOTE: Describe every abnormality in detail. Enter number of pertinent item,

PHYSICAL EVALUATION before each comment. Use additional sheet if necessary.
EXAMINER’S
Check each item in appropriate column. NORMAL ABNORMAL
INITIALS
1. SKIN,LYMPHATICS
(identifying body marks, scars & tattoos)
2. HEAD,FACE, AND SCALP
3. NECK (mass, lymph nodes)
4. NOSE
5. MOUTH AND THROAT
6. EARS-GENERAL (int. & ext)
7. EAR DRUMS (perforation)
8. HEARING (WHISPER VOICE TEST)
RIGHT WV ____ / 15 LEFT WV ____ / 15
9. EYES (general appearance)
10. PUPILS (size, reactions), VISUAL FIELD
11. OCULAR MOTILITY (EOM)
12. DISTANT VISION
RIGHT __ - - /__ PINHOLE __/__
LEFT __/__ PINHOLE __/__
13. NEAR VISION
RIGHT J _____ LEFT J _____
14. COLOR VISION (ISHIHARA)
15. LUNGS AND CHEST (include breasts)
16. HEART (PMI, rhythm, murmur)
17. PERIPHERAL VASCULAR (varicosities)
18. ABDOMEN (note for hernia)
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19. ANUS AND RECTUM
20. GENITALIA
21. UPPER EXTREMITIES (strength, range of motion)
22. LOWER EXTREMITIES(strength, range of motion)
23. SPINE, MUSCULOSKELETAL
24. NEUROLOGIC
FEMALES ONLY (check how done) 26. OBSTETRIC SCORE
G___ P ___ (__ __ __ __) ( ) NSD ( ) C/S
25. PELVIC
( ) VAGINAL ( ) RECTAL LMP ________________ ( ) ABORTION

CHEST X-RAY, ECG, AND LABORATORY EXAMINATION

CXRAY (PLACE, DATE, FILM NUMBER, RESULT) ECG (PLACE, DATE, INTERPRETATION)

HEMATOLOGY URINALYSIS BLOOD CHEMISTRY SEROLOGY

COMPLETE BLOOD COUNT FBS RPR / VDRL

CREA HBs Ag

OTHERS: ANTI-HBS
PREGNANCY TEST
ABO & RH BLOOD TYPE

OTHER TESTS/ANCILLARY PROCEDURES:

ADDITIONAL CLINICAL NOTES: PHYSICAL PROFILE SUFFIX

P U L H E S R T D O

SUMMARY OF DEFECTS NOTED/DIAGNOSIS (basis for disqualification):

RECOMMENDATIONS: PHYSICAL HEALTH

 PHYSICALLY FIT FOR POLICE SERVICE PROFILE
 FIT FOR POLICE SERVICE BUT WITH RESTRICTIONS, specify;_________________________
 TEMPORARILY UNFIT FOR POLICE SERVICE FOR ___________ MONTHS
 PERMANENTLY UNFIT FOR POLICE SERVICE

I hereby certify that I have seen and thoroughly examined this applicant together with his/her laboratory
results that lead to the above recommendation/s.

__________________________________ _____________________
SIGNATURE OVER PRINTED NAME DATE EVALUATED
MEDICAL OFFICER
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