BJMP DHS Form No.

005

BUREAU OF JAIL MANAGEMENT AND PENOLOGY DATE: _____________

Directorate for Health Service -NHQ ( ) ANNUAL ( ) SCHOOLING
Email: bjmphealthservice@gmail.com ( ) PROMOTION ( ) RECRUITMENT

MEDICAL EXAMINATION RECORD

RANK/ LAST NAME, FIRST NAME, MIDDLE NAME CONTACT NO. REGION/OFFICE (QUOTA)

ADDRESS AGE SEX CIVIL STATUS RELIGION

DATE OF BIRTH PLACE OF BIRTH NAME OF THE NEXT KIN/RELATIONSHIP

VITAL SIGNS PHYSICAL EXAMINATION

Normal Remarks
BP _____/_____ Pulse ______ RR ______ T _____ General Appearance
Mental Status
VISUAL ACQUITY
Skin
(R) 20/______ (L) 20/______ Head & Neck
EENT
Color vision _______________________
Chest (Heart/Lungs)
Musculo-Skeletal
WAIST CIRCUMFERENCE (cm) __________
Extremities
HEIGHT (m) ________ WEIGHT (kg) ________ Abdomen
Anal/Inguinal/Genitalia
BMI _________ ( ) Normal Other significant findings:
( ) Over Weight ( ) Underweight
( ) Obese ___

SYSTEMS REVIEW
In the past month, have you had any of the following problems?
GENERAL THROAT SKIN PSYCHIATRIC
 Recent weight gain  Frequent sore throats  Redness  Depression
 Recent weight loss  Hoarseness  Rash  Excessive worries
 Fatigue  Difficulty in swallowing  Nodules/bumps  Difficulty falling asleep
 Weakness  Pain in jaw  Hair loss  Difficulty staying asleep
 Fever  Color changes of hands or feet  Difficulties with sexual arousal
 Night sweats HEART AND LUNGS  Poor appetite
 Chest pain BLOOD  Food cravings
NERVOUS SYSTEM  Palpitations  Anemia  Frequent crying
 Headaches  Shortness of breath  Clots  Sensitivity
 Dizziness  Fainting  Thoughts of suicide / attempts
 Fainting/loss of consciousness  Swollen legs or feet KIDNEY/URINE/BLADDER  Stress
 Numbness or tingling  Cough  Frequent or painful urination  Irritability
 Memory loss  Blood in urine  Poor concentration
STOMACH AND INTESTINES  Racing thoughts
EARS  Nausea MUSCLE/JOINTS/BONES  Hallucinations
 Ringing in ears  Heartburn  Numbness  Rapid speech
 Loss of hearing  Stomach pain  Joint pain  Guilty thoughts
 Vomiting  Muscle weakness  Paranoia
EYES  Yellow jaundice  Joint swelling  Mood swings
 Pain  Increasing constipation Where?  Anxiety
 Redness  Persistent diarrhea  Risky behavior
 Loss of vision  Blood in stools Women Only:
 Double or blurred vision  Black stools  Abnormal Pap smear OTHER PROBLEMS:
 Dryness  Irregular periods
 Bleeding between periods
 PMS

PREVIOUS OPERATIONS/HOSPITALIZATION VACCINES ALLERGIES

(Last 5 years)

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BJMP DHS Form No. 005

PAST MEDICAL HISTORY

( ) Diabetes ( ) Typhoid
( ) High blood pressure ( ) Colitis
( ) High cholesterol ( ) Hemorrhoids
( ) Angina ( ) Kidney disease
( ) Heart murmur ( ) Kidney stones
( ) Heart problems ( ) Anemia
( ) Asthma ( ) Rheumatic fever
( ) Pneumonia ( ) Hernia
( ) COPD ( ) Cataract
( ) Emphysema ( ) STD
( ) Pulmonary embolism ( ) Dengue
( ) Spinal Injury ( ) Malaria
( ) Hypothyroidism ( ) Arthritis/Rheuma
( ) Goiter ( ) Tuberculosis
( ) Stroke ( ) HIV/AIDS
( ) Epilepsy (seizure) ( ) Insomia
Remarks:
( ) Stomach/peptic ulcer ( ) Mental Disorder
( ) Jaundice ( ) Substance Abuse
( ) Hepatitis ( ) Skin lesions
( ) Cancer (type) ______ ( ) Others ___________

CURRENT MEDICATIONS FAMILY HISTORY SOCIAL HISTORY (Female) OBSTETRICS

( ) Hypertension ( ) Tobacco
( ) Diabetes ( ) Alcohol G__ P__ (_ _ _ _ )
( ) Illicit drugs LMP: _________________
( ) Others ____________ ( ) Diet _______________ Pain: _________________

DIAGNOSTIC RESULTS
Test Results SI Units Traditional Units Other Reference
Complete Blood Count
Hemoglobin (Male) 140-180 g/L 14.0-18.0 g/dL
(Female) 120-160 g/L 12.0-16.0 g/dL
Hematocrit (Male) 0.40-0.54 40%-54%
(Female) 0.37-0.47 37%-47%
Red Blood Cell 4.2-6.2 x 1012 cells/L 4.2-6.2 x 106 cells/µL
White Blood Cell 3.5-12.0 x 109/L 3,500-12,000/mm3
Platelet 150-400 x 109/L 150-400 x 10 3 µl
Neutrophil 3000-5800 x 106/L 50%-81%
Lymphocytes 1500-3000 x 106/L 14%-44%
Eosinophil 50-250 x 106/L 1-5%
Monocyte
Basophil 15-50 x 106/L 0-1%
Blood Chemistry
FBS 3.9-6.1 mmol/L 70-110 mg/dL
Uric Acid 120-420 µmol/L 2.0-7.0 mg/dL
BUN 8.0-16.4 mmol/L 22-46 mg/dL
Creatinine 50-110 µmol/L 0.6-1.2 mg/dL
Total Cholesterol <5.2 mmol/L <200mg/dL
Tryglycerides 0.45-1.71 mmol/L 40-150 g/dL
HDL >0.91 mmol/L >35mg/dL
LDL <3.4 mmol/L <130 mg/dL
VLDL 0.1-1.7 mmol/L 2-30 mg/dL
SGPT 7-56 IU/L 0-35 U/L
SGOT 5-40 IU/L 17-59 U/L
*References for Normal Values may vary from different diagnostic centers, kindly record accordingly. hso20 18

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BJMP DHS Form No. 005

Blood Type:
HbsAg:
VDRL:
Electro-Cardiogram (ECG):
Chest X-ray (PA view):
Drug Test:
Pregnancy Test:
Others:
CLINICAL MICROSCOPY
Urinalysis
Fecalysis

PSYCHOLOGICAL/PSYCHIATRIC TEST I hereby certify that I revealed true and correct medical history.
Remarks

____________________________________
Signature over printed Name of Personnel

PHYSICAL EXAMINATION CLASSIFICATION

CLASS A RECOMMENDATIONS/INTRUCTIONS
- Physically Fit (to Work/undergo Training/PFT)
- No medical condition/physical defect noted ( ) RECOMMENDED
- To perform & execute the standard PFT/physical activities ( ) NOT RECOMMENDED
CLASS B1
- Fit to Work/undergo Training but with controlled medical
PHYSICAL FITNESS CLASSIFICATION:
condition or correctible physical defects
E.g. controlled HTN, controlled DM, tolerable arthritis, error of ( ) CLASS A ___________________________________________
refraction, dental carries, hearing defect, etc.
- To perform/execute standard PFT/physical activities with
( ) CLASS B1 __________________________________________
monitoring
CLASS B2
- May undergo Training but with medical condition that may ( ) CLASS B2 ___________________________________________
need monitoring & regular follow up
E.g. uncontrolled HTN, uncontrolled DM, joint pathology with ( ) CLASS C ___________________________________________
intermittent joint pains including gout & ligament
insufficiency; back pains/ back problems ( ) CLASS D ___________________________________________
- May perform/execute PFT/physical activities as tolerated
and/or perform alternative physical activities
( ) CLASS X ___________________________________________
CLASS C
- Employable/may undergo training but requires one or more of
the following:
 Maintenance medication & Follow up treatment
 Periodic evaluation Medical Officer ____________________________________
 Limited duty/activity
 Special Assignment License # _____________________________
- Post surgery with metal implants, with limitation of
movement; amputation, use of prosthesis
- For alternative physical activities that able to perform/execute
CLASS D
- Temporarily Unfit and/or unsafe to work of any kind
E.g. active PTB, particular post-surgical procedures, post CS/NSD.
CLASS X
- UNFIT for employment, UNFIT to undergo training/PFT
E.g. s/p brain attack/stroke with neurological deficiency, paralyzed,
aneurysm survivor, COPD, heart failure/bi-pass surgery; kidney
failure/CKD/ESRD; end stage carcinoma; undergoing dialysis or
chemotherapy

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BJMP DHS Form No. 005

DENTAL RECORD

LEGEND:
Present Condition Diseases/Abnormalities
X - missing/for extraction X – for extraction
O - light cure restoration O – for restoration
O - amalgam restoration
/// - porcelain/plastic jacket restoration
^ - spacing

REMARKS

Dental Officer ________________________

License # ____________________________
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