Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar, Philippines
Web: uep.edu.ph; Email: uepnsofficial@gmail.com

GSP ORGANIZATION

Date: ________________

Name: ___________________________________ Contact Number:

____________________
Year and Section: __________________________ Age: ______________________________
Scouting Event: ______________________________________________________________
Address:
____________________________________________________________________
Mother: __________________________________ Contact Number: ___________________
Father: ___________________________________ Contact Number: ___________________
___________________________________________________________________________

PHYSICAL EXAMINATION (To be filled out by a licensed Physician)

NOTE: Please indicate if NORMAL, otherwise, write your remarks for the abnormalities
noted:

Height______________________________ Blood Pressure___________________________

Weight_____________________________ Circulatory System _______________________
Skin________________________________ Nervous System__________________________
Head_______________________________ Loco-Motor
System________________________
Eyes_______________________________ Laboratory Examinations

With Glasses: ECG______________________________

Right___________ Left_____________ Chest X-ray________________________
Ears__________________________________ Blood Analysis_____________________
Nose_________________________________ Urinalysis_________________________
Teeth_________________________________ Immunization
Neck__________________________________ Smallpox__________ Tetanus________
Throat________________________________ Cholera___________ Polio___________
Thorax________________________________ Hepatitis__________ Measles________
Heart___________________________ Others___________________________
Lungs___________________________ Menstrual History__________________
Abdomen______________________________ ___________________________
Genitalia_________________________ Allergy (drugs, food, materials)
________
Hernia (if present) _________________ ___________________________
RECOMMENDATIONS AND RESTRICTIONS (Diet, medicine, activities, others)
___________________________________________________________________________
___________________________________________________________________________

_________________________________
Signature of Physician
 _________________________________
License No.______________________ Printed Name of Physician
Date ___________________________ _________________________________
Republic of the Philippines
Address ________________________ Date
UNIVERSITY OF EASTERN PHILIPPINES
Phone No. ______________________
University Town, Northern Samar, Philippines
Web: uep.edu.ph; Email: uepnsofficial@gmail.com

BSP ORGANIZATION

Date: ________________

Name: ___________________________________ Contact Number:

____________________
Year and Section: __________________________ Age: ______________________________
Scouting Event: ______________________________________________________________
Address:
____________________________________________________________________
Mother: __________________________________ Contact Number: ___________________
Father: ___________________________________ Contact Number: ___________________
___________________________________________________________________________

PHYSICAL EXAMINATION (To be filled out by a licensed Physician)

NOTE: Please indicate if NORMAL, otherwise, write your remarks for the abnormalities
noted:

Height______________________________ Blood Pressure___________________________

Weight_____________________________ Circulatory System _______________________
Skin________________________________ Nervous System__________________________
Head_______________________________ Loco-Motor
System________________________
Eyes_______________________________ Laboratory Examinations

With Glasses: ECG______________________________

Right___________ Left_____________
Ears__________________________________
Nose_________________________________
Teeth_________________________________
Neck__________________________________
Throat________________________________
Thorax________________________________
Heart___________________________
Lungs___________________________
Abdomen______________________________
Genitalia_________________________
________
Hernia (if present) _________________
Chest X-ray________________________
Blood Analysis_____________________
Urinalysis_________________________
Immunization
Smallpox__________ Tetanus________
Cholera___________ Polio___________
Hepatitis__________ Measles________
Others___________________________
Menstrual History__________________
___________________________
Allergy (drugs, food, materials)
___________________________
RECOMMENDATIONS AND RESTRICTIONS (Diet, medicine, activities, others)
___________________________________________________________________________
___________________________________________________________________________

License No.______________________
Date ___________________________
Address ________________________
Phone No. ______________________
_________________________________
Signature of Physician
_________________________________
Printed Name of Physician
_________________________________
Date