Republic of the Philippines

NATIONAL POLICE COMMISSION

PHILIPPINE NATIONAL POLICE, HEALTH SERVICE
REGIONAL MEDICAL AND DENTAL UNIT 1
Camp BGen Oscar M Florendo, Parian, City of San Fernando, La Union

PFT MEDICAL EVALUATION FORM

DATE: _______________________ CONTROL NO. ___________________

RANK LAST NAME FIRST NAME MIDDLE NAME AGE SEX CIVIL STATUS

UNIT/UNIT ADDRESS CONTACT NUMBER

DATE OF BIRTH PLACE OF BIRTH RELIGION PURPOSE OF EXAMINATION

HEIGHT WEIGHT BMI BP 1st BP 2nd ECG

NEXT OF KIN (NAME, RELATIONSHIP, ADDRESS, CONTACT NO.)

INSTRUCTION: The instructions contained hereto and in the other medical forms are pertinent and vital. They shall be part of the personnel’s medical records. The
information you will give shall constitute an official statement. They are to be filled-up properly, honestly and with utmost integrity. If you are
accepted into the PNP based on a false statement herein you can be recommended for summary dismissal proceedings in the future.
PLEASE CHECK AND WRITE YOUR ANSWERS ON THIS QUESTIONNAIRE ON THE SPACE PROVIDED
(may use additional sheet/s if necessary)

1. MEDICAL HISTORY: DO YOU HAVE ANY OF THE FOLLOWING?

Yes No Yes No Yes No
£ £ DIABETES £ £ CANCERS £ £ RECENT SURGERY
LEUKEMIA/BLEEDING
£ £ HEART DISEASE £ £ DISORDERS £ £ RECENT FRACTURE
£ £ HIGH BLOOD PRESSURE £ £ KIDNEY DISEASE £ £ RECENT INJURIES
£ £ ASTHMA/LUNG DISEASE £ £ LIVER DISEASE £ £ PREGNANCY
£ £ GOITER/THYROID DISEASE £ £ RECENT HOSPITALIZATION
OTHER DISEASE/S:______________________________________________________________________________________

2. FAMILY MEDICAL HISTORY: DO YOU HAVE ANY FAMILY MEMBER OR RELATIVE WHO HAVE ANY OF THE FOLLOWING?
Yes No CONDITIONS Yes No CONDITIONS Yes No CONDITIONS
PULMONARY GOITER/THYROID DISEASE
£ £ DIABETES £ £ TUBERCULOSIS
£ £
£ £ HEART DISEASE £ £ HEPATITIS £ £ CANCER

£ £ HYPERTENSION
£ £
KIDNEY DISEASE £ £ BLEEDING DISORDERS

£ £ ASTHMA/LUNG DISEASE £ £ LIVER DISEASE £ £ MENTAL DISORDER

3. PERSONAL/SOCIAL HISTORY
Yes No Yes No
£ £ SMOKING STICKS ___PER DAY SINCE______ £ £ ALCOHOL ___________ # PER MONTH
STOPPED DRINKING ALCOHOL
£ £ STOPPED SMOKING WHEN_____________ £ £ WHEN______________
4. WOMEN’S HEALTH HISTORY
MENSES INTERVAL MENSES DURATION LAST MENSTRUAL PERIOD: (DATE)

EVERY DAYS LASTING DAYS

REGULAR? £YES £NO DYSMENORRHEA? £YES £NO DO YOU PERFORM SELF-BREAST EXAMINATION? £YES £NO

NO. OF ABORTIONS/
NO. OF PREGNANCIES NO. OF DELIVERIES
MISCARRIAGES
£CEASARIAN £NORMAL
 5. MEDICATION AND ALLERGY HISTORY
A. CURRENT MEDICATIONS YOU ARE TAKING IF THERE ARE ANY: B. ALLERGIES TO MEDICATIONS, DRUGS OR FOOD, IF THERE ARE ANY:

6. PHYSICAL FITNESS TEST READINESS QUESTIONNAIRE. THIS QUESTIONNAIRE IS BEING GIVEN TO THE PARTICIPANT
BEFORE THE PFT, THIS SECTION MAY BE USED FOR LEGAL AND/OR ADMINISTRATIVE PURPOSES.
TO BE ACCOMPLISHED BY THE PARTICIPANT: PLEASE READ CAREFULLY AND ANSWER EACH ONE HONESTLY: CHECK YES OR NO.
YES NO
1. HAS YOUR DOCTOR EVER SAID YOU HAVE A HEART CONDITION AND THAT YOU SHOULD ONLY DO PHYSICAL ACTIVITY
£ £ RECOMMEND BY A DOCTOR?
£ £2. DO YOU FEEL PAIN IN YOUR CHEST WHEN YOU DO PHYSICAL ACTIVITY?
£ £3. IN THE PAST MONTH, HAVE YOU HAD CHEST PAIN EVEN WHEN YOU ARE NOT DOING PHYSICAL ACTIVITY?
£ £4. DO YOU EXPERIENCE SHORTNESS OF BREATH OR DIFFICULTY IN BREATHING WHEN DOING PHYSICAL ACTIVITY?
£ £5. HAS ANY DOCTOR EVER SAID YOU HAVE DIABETES OR INCREASED BLOOD SUGAR?
£ £6. HAVE YOU HAD BLOOD PRESSURE OVER 140/90?
£ £7. DO YOU LOSE BALANCE BECAUSE OF DIZZINESS OR DO YOU EVER LOSE CONSCIOUSNESS?
8. DO YOU HAVE A BONE OR JOINT PROBLEM? FOR EXAMPLE, KNEE OR HIP THAT COULD BE MADE WORSE BY A
£ £ CHANGE IN PHYSICAL ACTIVITY?
9. HAVE YOU HAD FEVER, COUGH, COLDS OR EVEN VEHICULAR ACCIDENT IN THE PAST WEEK THAT REQUIRED BED
£ £ REST?
£ £10. DO YOU KNOW ANY OTHER REASON WHY YOU SHOULD NOT DO ANY PHYSICAL ACTIVITY?
“I HAVE READ, UNDERSTOOD AND COMPLETED THE QUESTIONNAIRE. I ATTEST THAT THE ABOVE INFORMATION ARE
TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.”

________________________________________________________ ___________________________
NAME/SIGNATURE OF PNP PERSONNEL FOR PFT DATE

FOR MEDICAL OFFICERS

7. PERTINENT PHYSICAL EXAMINATIONS: ECG RESULT:

8. DIAGNOSIS / ASSESSMENT: PHYSICAL PROFILE

9. PLAN/RECOMMENDATION/S:

10. PFT REMARKS:

 GO ______________________  NO GO DUE TO
_______________________________
 OBSTETRICALLY DEFERRED  FOR ALTERNATE
PFT__________________________

SEEN AND EVALUATED BY:

____________________________________________________
SIGNATURE OVER PRINTED NAME OF MEDICAL OFFICER