Medical Form

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Tubban JAy-ARe

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Republic of the Philippines

Department of Education
CORDILLERA ADMINISTRATIVE REGION
SCHOOLS DIVISION OF APAYAO
UPPER/ LOWER CALANASAN DISTRICT

MEDICAL FORM
Name: ___________________ Age: _____ Civil Status: ___________ School: __________________
Designation: _____________ Weight: _______ Height: ___________ BP: ____ CP No. ______________

1. Chest X-RAY_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

2. FBS/RBS _____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

3. Cholesterol _____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

4. Complete Blood Count (CBC) _______________________________________________________________

_____________________________________________________________________________
_____________________________________________________________________________

5. Urinalysis _____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

6. Electro-Cardiogram (Optional) _______________________________________________________________

_____________________________________________________________________________
_____________________________________________________________________________

7. Pap Smear (Optional) ______________________________________________________________________

_____________________________________________________________________________
_____________________________________________________________________________

Remarks _____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

____________________________________
Physician
License no. ___________________________

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