Professional Regulation Commission

: RECORD OF CONDUCTED INTERNAL EXAMINATION BEFORE DELIVERY

Please Check:
✓ Graduate Midwife Registered Nurse

Name of Applicant: School: DR. JOSE FABELLA MEMORIAL HOSPITAL – SCHOOL OF MIDWIFERY

Internal Examination Supervised by:

Ca Date & Full Name, License
(Cervical Dilation, Position
Name and Address se Time Address of Printed Name
Effacement, BOW, / No./
of Patient N Perform Facility & & Contact Signature
Presentation & Designati Expiration
o. ed Contact Number No.
Station) on Date
1. Gravida 3 Para 2 (2002) Pregnancy Uterine 40 weeks Dr. Jose Fabella Memorial Eleonor B. Diaz Clinical Instructor RM License#: 0129315
Age of Gestation by Last Menstrual Period, 10 Hospital, Lope de Vega St. Sta. 87345561 loc. 135 Expiry date: 02/24/2027
centimeters cervical dilatation, 100 % effaced, ruptured
Cruz, Manila, 87345561 loc. 135
bag of water, clear amniotic fluid, cephalic in labor,
station +2
2. Gravid 3 Para 2 (2002) Pregnancy Uterine 38 4/7 weeks Dr. Jose Fabella Memorial Eleonor B. Diaz Clinical Instructor RM License#: 0129315
Age of Gestation by Last Menstrual Period,10 Hospital, Lope de Vega St. Sta. 87345561 loc. 135 Expiry date: 02/24/2027
centimeters cervical dilatation, 100 % effaced, ruptured
Cruz, Manila, 87345561 loc. 135
bag of water, clear amniotic fluid, cephalic in labor,
station +2
3. Gravida 4 Para 3 (3003) Pregnancy Uterine 40 weeks Dr. Jose Fabella Memorial Sarah Jean S. Turbolencia Clinical Instructor RM License#: 0146667
Age of Gestation by Last Menstrual Period, 9 centimeters Hospital, Lope de Vega St. Sta. 87345561 loc. 135 Expiry date: 09/26/2026
cervical dilatation, 90 % effaced, ruptured bag of water,
Cruz, Manila, 87345561 loc. 135
clear amniotic fluid, cephalic in labor, station +1
4. Gravida 2 Para 1 (1001) Pregnancy Uterine 40 weeks Dr. Jose Fabella Memorial Sarah Jean S. Turbolencia Clinical Instructor RM License#: 0146667
Age of Gestation by Last Menstrual Period, 9 centimeters Hospital, Lope de Vega St. Sta. 87345561 loc. 135 Expiry date: 09/26/2026
cervical dilatation, 90% effaced, ruptured bag of water,
Cruz, Manila, 87345561 loc. 135
clear amniotic fluid, cephalic in labor, station +2
5. Gravida 4 Para 3 (3003) Pregnancy Uterine 39 5/7 Dr. Jose Fabella Memorial Marjorie M. Palconit Clinical Instructor RM License#: 0164737
weeks Age of Gestation by Last Menstrual Period, 7 Hospital, Lope de Vega St. Sta. 87345561 loc. 135 Expiry date: 05/25/2025
centimeters cervical dilatation, 70 % effaced, intact bag
Cruz, Manila, 87345561 loc. 135
of water, cephalic in labor, station +1
6. Gravida 4 Para 3 (3003) Pregnancy Uterine 39 weeks Dr. Jose Fabella Memorial Marjorie M. Palconit Clinical Instructor RM License#: 0164737
Age of Gestation by Last Menstrual Period, 9 centimeters Hospital, Lope de Vega St. Sta. 87345561 loc. 135 Expiry date: 05/25/2025
cervical dilatation, 90% effaced, ruptured bag of water,
Cruz, Manila, 87345561 loc. 135
clear amniotic fluid, cephalic in labor, station +2
7. Gravida 2 Para 1 (1001) Pregnancy Uterine 38 2/7 Dr. Jose Fabella Memorial Mabel Angelique M. Martinez Clinical Instructor RM License#: 0168834
weeks Age of Gestation by Last Menstrual Period, 9 Hospital, Lope de Vega St. Sta. 87345561 loc. 135 Expiry date: 04/13/2027
centimeters cervical dilatation, 100 % effaced, ruptured
Cruz, Manila, 87345561 loc. 135
bag of water, clear amniotic fluid, cephalic in labor,
station +1
8. Gravida 4 Para 3 (3003) Pregnancy Uterine 39 4/7 Dr. Jose Fabella Memorial Eleonor B. Diaz Clinical Instructor RM License#: 0129315
weeks Age of Gestation by Last Menstrual Period, 10 Hospital, Lope de Vega St. Sta. 87345561 loc. 135 Expiry date: 02/24/2027
centimeters cervical dilatation, 100% effaced, ruptured
Cruz, Manila, 87345561 loc. 135
bag of water, clear amniotic fluid, cephalic in labor,
station +2
9. Gravida 2 Para 1 (1001) Pregnancy Uterine 38 weeks Dr. Jose Fabella Memorial Russel Shane R. Pontillas Clinical Instructor RM License#: 0153520
Age of Gestation by Last Menstrual Period, 8 centimeters Hospital, Lope de Vega St. Sta. 87345561 loc. 135 Expiry date: 10/30/2025
cervical dilatation, 80 % effaced, intact bag of water,
Cruz, Manila, 87345561 loc. 135
cephalic in labor, station +1
10. Gravida 2 Para 1 (1001) Pregnancy Uterine 40 weeks Dr. Jose Fabella Memorial Sarah Jean S. Turbolencia Clinical Instructor RM License#: 0146667
Age of Gestation by Last Menstrual Period, 10 Hospital, Lope de Vega St. Sta. 87345561 loc. 135 Expiry date: 09/26/2026
centimeters cervical dilatation, 100% effaced, ruptured
Cruz, Manila, 87345561 loc. 135
bag of water, clear amniotic fluid, cephalic in labor,
station +2

(Continued at the Back) PRBSEC-47

Rev. 00
January 24, 2020
Page 1 of 1
 Internal Examination Supervised
Date & Full Name, by:
Name and Address Ca (Cervical Dilation,
Time Address of
of Patient se Effacement, BOW, License
Performe Facility & Printed Position
No Presentation & Signatur No./
d Contact Name & /
. Station) e Expiration
Number Contact Designati
Date
No. on
11. Gravida 3 Para 2 (2002) Pregnancy Uterine 40 weeks Dr. Jose Fabella Memorial Hospital, Marjorie M. Palconit Clinical Instructor RM License#: 0164737
Age of Gestation by Last Menstrual Period, 7 centimeters Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 05/25/2025
cervical dilatation, 70% effaced, ruptured bag of water,
87345561 loc. 135
clear amniotic fluid, cephalic in labor, station +1
12. Gravida 4 Para 3 (3003) Pregnancy Uterine 39 5/7 Dr. Jose Fabella Memorial Hospital, Sarah Jean S. Turbolencia Clinical Instructor RM License#: 0146667
weeks Age of Gestation by Last Menstrual Period, 10 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 09/26/2026
centimeters cervical dilatation, 100% effaced, ruptured
87345561 loc. 135
bag of water, clear amniotic fluid, cephalic in labor,
station +2
13. Gravida 3 Para 2 (2002) Pregnancy Uterine 38 1/7 Dr. Jose Fabella Memorial Hospital, Sarah Jean S. Turbolencia Clinical Instructor RM License#: 0146667
weeks Age of Gestation by Last Menstrual Period, 10 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 09/26/2026
centimeters cervical dilatation, 100 % effaced, ruptured
87345561 loc. 135
bag of water, clear amniotic fluid, cephalic in labor,
station +2
14. Gravida 5 Para 4 (4004) Pregnancy Uterine 38 weeks Dr. Jose Fabella Memorial Hospital, Erwin C. Daag Clinical Instructor RM License #: 0173761
Age of Gestation by Last Menstrual Period, 7 centimeters Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiration Date: 10/15/2026
cervical dilatation, 70 % effaced, ruptured bag of water, RN License # 0595434
87345561 loc. 135
clear amniotic fluid, cephalic in labor, station +1 Expiration Date: 10/15/2025
15. Gravida 2 Para 1 (1001) Pregnancy Uterine 37 2/7 Dr. Jose Fabella Memorial Hospital, Lyrica Mae G. De Ade Clinical Instructor RM License#: 0178851
weeks Age of Gestation by Last Menstrual Period, 8 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 04/08/2025
centimeters cervical dilatation, 80% effaced, ruptured
87345561 loc. 135
bag of water, clear amniotic fluid, cephalic in labor,
station +2
16. Gravida 1 Para 0 (0000) Pregnancy Uterine 39 6/7 Dr. Jose Fabella Memorial Hospital, Lyrica Mae G. De Ade Clinical Instructor RM License#: 0178851
weeks Age of Gestation by Last Menstrual Period, 8 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 04/08/2025
centimeters cervical dilatation, 80 % effaced, ruptured
87345561 loc. 135
bag of water, clear amniotic fluid, cephalic in labor,
station +1
17. Gravida 2 Para 1 (1001) Pregnancy Uterine 37 weeks Dr. Jose Fabella Memorial Hospital, Lyrica Mae G. De Ade Clinical Instructor RM License#: 0178851
Age of Gestation by Last Menstrual Period, 8 centimeters Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 04/08/2025
cervical dilatation, 80 % effaced, ruptured bag of water,
87345561 loc. 135
clear amniotic fluid, cephalic in labor, station +1
18. Gravida 3 Para 2 (2002) Pregnancy Uterine 38 4/7 Dr. Jose Fabella Memorial Hospital, Sarah Jean S. Turbolencia Clinical Instructor RM License#: 0146667
weeks Age of Gestation by Last Menstrual Period, 9 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 09/26/2026
centimeters cervical dilatation, 90% effaced, ruptured
87345561 loc. 135
bag of water, clear amniotic fluid, cephalic in labor,
station +2
19. Gravida 2 Para 1 (1001) Pregnancy Uterine 40 weeks Dr. Jose Fabella Memorial Hospital, Eleonor B. Diaz Clinical Instructor RM License#: 0129315
Age of Gestation by Last Menstrual Period, 8 centimeters Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 02/24/2027
cervical dilatation, 80% effaced, ruptured bag of water,
87345561 loc. 135
clear amniotic fluid, cephalic in labor, station +1
20. Gravida 4 Para 3 (3003) Pregnancy Uterine 39 5/7 Dr. Jose Fabella Memorial Hospital, Eleonor B. Diaz Clinical Instructor RM License#: 0129315
weeks Age of Gestation by Last Menstrual Period, 7 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 02/24/2027
centimeters cervical dilatation, 70% effaced, ruptured
87345561 loc. 135
bag of water, clear amniotic fluid, cephalic in labor,
station +1

Note: 1) The Clinical Instructor should ensure the competence of the students in the performance of internal examinations before signing this form.
2) Registered Midwives/Clinical Instructors who supervise Students/Graduate Midwives/Registered Nurses and affix their signature in this Form must present a
Certificate of Training on the Expanded Functions of Midwife (R.A. 7392) pursuant to Board Resolution No. 07, Series of 2017, dated September 8, 2017.
 Professional Regulation Commission

RECORD OF CONDUCTED INTERNAL EXAMINATION BEFORE DELIVERY

Affix
Documentary Stamp
(to be posted on the last
CERTIFIED CORRECT: page)

Signature: Date:
Printed Name: Maria Ursulita R. Umali
Designation: __Midwifery School Principal II______
License Number: _________Expiry Date: _________
PRBSEC-47
Rev. 00
January 24, 2020
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PRBSEC-47
Rev. 00
January 24, 2020
Page 1 of 1