BATAAN PENINSULA STATE UNIVERSITY

BALANGA CAMPUS Telefax No.: (047) 237-3655

Don Manuel Banzon Avenue, Poblacion Email Address: balanga@bpsu.edu.com
City of Balanga, 2100 Bataan PHILIPPINES Website: www.bpsu.edu.ph

HEALTH SERVICES UNIT

BPSU-SAF-005 (Revision 3; January/2024) Date: _________________

MEDICAL EXAMINATION RECORD
(To be filled out by the student)
Name: Sex:
Address: Age:
Course/Year and Section: Contact # of Student:
Parent/Guardian: Contact # of Parent/Guardian:
Date of birth: Email:
Past Medical History:

⃝ Tuberculosis/Pneumonia ⃝ Bronchial Asthma

⃝ Hepatitis ⃝ Epilepsy/Seizure
⃝ Typhoid ⃝ Heart Diseases
⃝ Dengue Food/Medicine Allergy
⃝ Sexually Transmitted Diseases Smoker/Alcohol Drinker
Others: Previous Hospitalization
Female only: Last Menstrual Period (1st Day of Last Menstruation):
I hereby affirm that the information provided on this form is true and complete. I hereby authorize BPSU to collect and process the data indicated herein for the
purpose of medical records and effective control of the Covid-19 infection. I understand that any personal information is protected by R.A. 10173, Data Privacy
Act of 2012 and I am required by R.A. 11469, bayanihan to Heal as One Act to provide truthful information.

Signature of the student

(To be filled out by the physician)
Pertinent Physical Examination Findings: Vital Signs:

H.E.E.N.T: ⃝ Normal Abnormalities: Weight Height

Chest & Lungs : ⃝ Normal Abnormalities:
BP PR
Heart: ⃝ Normal Abnormalities:
Abdomen: ⃝ Normal Abnormalities: Temp O2 Sat
Skin & Extremities: ⃝ Normal Abnormalities:
Laboratory Results:

Complete Blood Count: ⃝ Normal Abnormalities:

Urinalysis: ⃝ Normal Abnormalities:
Chest X-ray ⃝ Normal Abnormalities:
Others ⃝ Normal Abnormalities:

He/She belongs to:

( ) Class A- Physically fit for any work.
( ) Class B- Physically developed but with correctable defects (error of refraction, dental caries, defective
hearing and similar defects) but otherwise fit to work.
( ) Class C- Employable but owing to certain impairment (heart disease, hypertension, anatomical defects, etc.)
require placement or limited duty in a specified assignment requiring follow up treatment periodic evaluation.
( ) Class D- Unfit or unsafe for any type of employment (active PTB, advance heart disease with threatened
failure, malignant hypertension and other similar illnesses).
REMARKS/RECOMMENDATIONS:

ESSENTIALLY NORMAL AND FIT FOR OFF CAMPUS ACTIVITY

ON THE JOB TRAINING SCHOLARSHIPS

TOURS CONFERENCE, SYMPOSIUM, COMPETITION
SEMINARS/TRAININGS OTHERS:
SCUAA

MEDICAL OFFICER:
BPSU-SAF-005 (Revision 3; January/2024)

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