PHILIPPINE CIVIL SERVICE
MEDICAL CERTIFICATE
I hereby waive all rights and privileges pertaining to professional confidence between physician and
patients, and physician accomplishing this form is authorized to answer in detail question contained herein.
______________________________
Signature of Patient
Attending physician should fill in blank below, every detail should be answer to avoid delay in action an
application for leave be submitted by the patient __________________________________________________
of the bureau ___________________________________________ on account of illness I do hereby certify that
I was the applicant’s actual attending physician from __________________ 20 ____ to ____________________
20 ______ inclusive and from my professional knowledge of the case the following statements are submitted as
contemplated by provision of Section 8 of Civil Service XIV.
Name of disease or disability _____________________________________________________________
Name of disease or disability _____________________________________________________________
Under this heading, in addition to giving fully the etiology of the disease or disability, the
ETIOLOGY physician must either state in Language of the Executive Order. “There are no indications
whatever that the disease name was due to immoral or vicious habits” or give the indication.
__________________________________________________________________________________________
__________________________________________________________________________________________
HISTORY __________________________________________________________________________________
__________________________________________________________________________________________
DESCRIPTION _______________________________________________________________________________
A laboratory test Examination _________________________________________________ in this case
The applicant was confined to her/his home/hospital from ______________________________, 20____
to _________________________________________, 20______________.
I HEREBY CERTIFY that the above statement are complete and true in every detail, in that in consequence
of the disease or disability above specified the applicant was ill unable to be on duty on account of illness from
_________________________, 20_______ to __________________________, 20________ inclusive and that
his/her claim is meritorious.
(Signature) ____________________________________M.D
(P.O Address) __________________________________
Doc. Stamp
___________________________, 20________
CSC FORM NO. 211 (Revised August 1998) PHILIPPINE CIVIL SERVICE
MEDICAL CERTIFICATE
For Employment
INSTRUCTIONS
1. This medical certificate should be accomplished by a government physician.
2. Attached this certificate to original appointments and reinstatements.
__________________________________________________________________________________________
FOR THE PROPOSED APPOINTEE
NAME (Last, First, Middle, or if married woman, Maiden Name) AGENCY/ADDRESS
ADDRESS
AGE SEX CIVIL STATUS PROPOSED POSITION
Pre-Employment Medical – Physical Tests
1. Blood Test
2. Urinalysis
3. Chest X – Ray
4. Drug Test
5. Neuro-Psychiatric Examination (If necessary)
NOTE: ALL RESULTS OF EXAMINATIONS MUST BE ATTACHED TO THIS FORM.
FOR THE PHYSICIAN
AFFIX
I hereby certify that I have personally examined the above named
Documentary
individual and found her/him to be physically and medically fit/unfit
Stamp Here
for employment
PRINTED NAME / SIGNATURE OF PHYSICIAN CERTIFICATE NUMBER OTHER INFORMATION ABOUT THE
PROPOSED APPOINTEE
OFFICIAL DESIGNATION HEIGHT WEIGHT BLOOD
(bare Feet) (Stripped) Type
AGENCY DATE EXAMINED
Jv /DBB/629196
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