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Ape Blank Form

This document appears to be an annual physical examination report form for the Philippine National Police (PNP) Health Service. It collects personal information about a PNP member such as name, age, rank, address, medical history and physical measurements like height, weight and blood pressure. The form is then filled out by medical staff who note the results of examinations like chest x-rays, ECGs, visual acuity tests and physical health assessments. The medical officer provides a treatment plan, diagnosis and determines the member's physical health profile.

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Arlene Bermudez Pascual
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194 views1 page

Ape Blank Form

This document appears to be an annual physical examination report form for the Philippine National Police (PNP) Health Service. It collects personal information about a PNP member such as name, age, rank, address, medical history and physical measurements like height, weight and blood pressure. The form is then filled out by medical staff who note the results of examinations like chest x-rays, ECGs, visual acuity tests and physical health assessments. The medical officer provides a treatment plan, diagnosis and determines the member's physical health profile.

Uploaded by

Arlene Bermudez Pascual
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PNP HS FORM NO.

2014-06 Revised 2021

Republic of the Philippines


NATIONAL POLICE COMMISSION
PHILIPPINE NATIONAL POLICE
HEALTH SERVICE
Camp BGen Rafael T Crame, Quezon City

ANNUAL PHYSICAL EXAMINATION REPORT


CY 2023
DATE: CONTROL NO.
RANK LAST NAME FIRST NAME MIDDLE NAME QUALIFIER BADGE NO.

AGE SEX CIVIL STATUS UNIT ASSIGNMENT/ADDRESS

PERMANENT HOME ADDRESS (NUMBER, STREET, CITY OR TOWN PROVINCE) CONTACT NUMBER

DATE OF BIRTH PLACE OF BIRTH DATE ENTERED SVC LENGHTH OF SVC PURPOSE OF EXAMINATION
APE
NEXT OF KIN (Name, Relationship, Address, Contact No.)

THIS PART IS TO BE FILLED UP BY MEDICAL STAFF/ MEDICAL OFFICER


COLOR OF HAIR COLOR OF EYES BLOOD TYPE IDENTIFYING MARKS (birthmarks, scars, mole, tattoo, etc)

HEIGHT (cm) WEIGHT (kg) WAISTLINE (in) BP(mmHg) CAR (bpm) RR (cpm) TEMP (C)

YOUR
BMI RANGE ACCORDING TO AGE CARDIOVASCULAR Chest X-ray (result):
RISK IS:
51 y/o & NORMAL
40-44 y/o 45-50 y/o above CLASSIFICATION Family History
SEVERELY ECG (result):
< 17 < 17 < 17 Sedentary lifestyle
UNDERWEIGHT
(inactive)
17-18.4 17-18.4 17-18.4 UNDERWEIGHT Stressful life NORMAL
Overweight/Obesity
18.5-24.9 18.5-24.9 18.5-24.9 NORMAL
Diabetes BMI VISUAL ACUITY
25-26 25-26.5 25-27 ACCEPTABLE BMI Hypertension (wt in kg/ ht in m2)
26.1-29.9 26.6-29.9 27.1-29.9 OVERWEIGHT High Cholesterol
Smoking OD
30.0-34.9 30.0-34.9 30.0-34.9 OBESE CLASS 1
OS
35.0-39.9 35.0-39.9 35.0-39.9 OBESE CLASS 2 Risk: 0 of 8
✔Low Moderate
OU
>= 40 >= 40 >= 40 OBESE CLASS 3 High
FOR FEMALES: PERTINENT PHYSICAL EXAMINATION FINDINGS: COLOR VISION TEST
OBSTETRIC SCORE G_P_(_________)
LMP: MENARCHE :

NSD C/S x ABORTION

TREATMENT PLAN /ADVISE: ENT EXAMINATION:

FINAL DISPOSITION/DIAGNOSIS PHYSICAL HEALTH PROFILE


P1 P2 P3T P3P P4

Legend:

License Nr:
Medical Officer

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