(PDSCSW) PHYSICIANS' DIAGNOSTIC SERVICES CENTER FOR SEABASED WORKERS, INC.

- 533 UNITED
NATIONS AVENUE, 4TH FLOOR PHYSICIANS' TOWER ERMITA, MANILA, PHILIPPINES
ONLINE REGISTRATION FORM
FOR PRE-EMPLOYMENT MEDICAL

Reference No​: PG022151

PERSONAL INFORMATION

LAST NAME: FIRST NAME: MIDDLE NAME: GENDER: DATE OF BIRTH:

Armada James Aranas MALE 10/28/1980

CIVIL STATUS: RELIGION: NATIONALITY: PLACE OF BIRTH:

Married Roman catholic FILIPINO Mandaue city

ADDRESS: EMPLOYMENT TYPE: AGENCY:

Phase 1 subic hills village lot 16-17 Aningway Sea Base Jebsen
sacatihan subic zambales

EMAIL ADDRESS: CONTACT NO.: POSITION:

jamesarmada1980@gmail.com +639618430280 C/E

Note to Applicant: ​YOU ARE SCHEDULED FOR YOUR PRE-EMPLOYMENT MEDICAL EXAMINATION AT​ ​(PDSCSW)
PHYSICIANS' DIAGNOSTIC SERVICES CENTER FOR SEABASED WORKERS, INC. - 533 UNITED NATIONS
AVENUE, 4TH FLOOR PHYSICIANS' TOWER ERMITA, MANILA, PHILIPPINES
Kindly wait for our confirmation regarding your appointment schedule.
PLEASE NOTE THAT WE WILL STRICTLY BE IMPLEMENTING NO APPOINTMENT-NO ENTRY AND NO
MASK-NO ENTRY POLICIES. YOU ARE ALSO REQUIRED TO BRING 2 PRINTED COPIES OF YOUR
REFERRAL FORM OR ENDORSEMENT FROM THE AGENCY; OTHERWISE YOU WILL NOT BE ABLE TO
PROCEED WITH YOUR MEDICAL.
PLEASE REPORT TO THE CLINIC ON YOUR APPOINTMENT SLOT. WE WILL STRICTLY FOLLOW THE APPOINTMENT SCHEDULE
FOR EVERYONE’S SAFETY.

THINGS TO KNOW BEFORE YOUR MEDICAL APPOINTMENT:

GENERAL GUIDELINES:
1. For your safety and the safety of our staff, we will be strictly implementing a ​NO MASK AND FACE
SHIELD-NO ENTRY POLICY. Also, DO NOT REMOVE YOUR MASK AND FACE SHIELD WHILE INSIDE THE
CLINIC UNLESS REQUIRED FOR SOME TESTS. Please wear medical grade/surgical masks, ​MASKS WITH
VALVES WILL NOT BE ALLOWED INSIDE THE CLINIC.
2. Only examinees will be allowed to enter the clinic. No companions allowed.
3. To avoid delays, ​bring printed copies of the following:
a. Online Registration Form
b. Referral/Endorsement from your agency
c. Valid Passport and Seaman's Book

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 4. Be at the triage area 10 minutes before your appointment. You will need to show the text message from
our clinic stating your appointment date and time. ​YOU WILL NOT BE ALLOWED TO ENTER IF YOU DO
NOT HAVE AN APPOINTMENT OR IF IT IS NOT YET YOUR APPOINTMENT TIME.

THINGS TO BRING:
1. One (1) 2x2 recent ID picture
2. Original and photocopy of valid government issued ID
3. If available, photocopy of updated passport and seaman's book
4. Thumb size sample of your stool in a small container. Label the bottle with your complete name, age, and
name of agency.
5. Vaccination card, if any.
6. Eyeglasses (for applicants who are using eyeglasses/reading glasses)
7. Medical records of any previous treatments, recent hospitalizations, operating room records for surgical
operations, old chest x-ray films for those with previous x-ray findings for comparative study.
SPECIAL INSTRUCTIONS FOR MEDICAL EXAMINATIONS:
● FOR PROPER FASTING - ​ ​Do not eat or drink within 8 to 10 hours before blood sample extraction or
Liver/Gallbladder Ultrasound Procedures.​ F​ ailure to comply may lead to delays and repeat medical
testing. For your convenience, please follow the table below:

TIME OF APPOINTMENT LATEST TIME THAT YOU SHOULD EAT/DRINK

8am 11pm (night before)

9am 12 midnight

10am 2AM

11am 3AM

1pm 5AM

2pm 6AM

3pm 6AM
● FOR THOSE WHO WILL UNDERGO LIVER FUNCTION TESTS, it is advised that you refrain from alcohol
intake and avoid fatty foods for at least two (2) weeks prior to examination.
● FOR APPLICANTS WHO WILL BE UNDERGOING FUNCTIONAL CAPACITY EVALUATION (FCE) OR CHESTER
STEP:
1. Please note the following:
a. Must have eaten at least 1 hour before FCE
b. Ceased smoking/alcohol intake at least 1 week prior to FCE.
c. Should not drink coffee, tea or softdrinks on the date of FCE.
d. Diet should be low in salt or fat, at least 3 days before FCE.
e. FCE will not be performed on individuals who have or just had colds, cough or fever.
2. Things to bring:
a. Rubber shoes and socks.
b. Extra loose fitting t-shirt.
c. Jogging pants or basketball shorts
d. 1 liter of water
e. Small towel
Note: FCE is not done on the same day as the medical exam; you will be contacted by the clinic for your schedule.

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 NOTE: This is a computer generated message please do not reply.

HEALTH DECLARATION:
Travel History (If Repatriated for reasons related to COVID 19 pandemic):
When was your last date of arrival to the Philippines?
What Country of Origin?

Listed below are the following signs and symptoms which you have experienced in last 14 days:

Places you have visited during the last 14 days (Kindly provide the addresses or barangays and cities)
Olongapo city
Have you been in contact or are living with a household member that was diagnosed with COVID-19 in the
past one month? No
Do you have a household member who is presently sick or experiencing cough or fever? No

☐​ I hereby declare that the information disclosed are true and correct based on my personal knowledge.

☐​ I hereby authorize PDSC Clinics to use the information that I have provided above for my PEME application and
processing. I also authorize the clinic to share my data with my agency and employer.

PRINTED NAME AND SIGNATURE DATE NAME AND SIGNATURE OF SCREENING DATE
NURSE

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