PNP HS FORM NO.
2012-04
2x2 colored picture with
Republic of the Philippines white background and
Department of the Interior and Local Government the name should appear
NATIONAL POLICE COMMISSION below the picture
Philippine National Police (LAST,FIRST, M.I. &
HEALTH SERVICE BELOW IS THE RANK).
Camp Crame, Quezon City
PHYSICAL EXAMINATION REPORT
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 SERVICE LENGTH OF SERVICE PURPOSE OF EXAMINATION
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 (Co)
BMI (wt in ( ) UNDERWEIGHT ≤ 18.5 FOR FEMALES: CXR (result) VISUAL ACUITY
kg / ht in m2): ( ) NORMAL 18.5 - ≤ 25 OBSTETRIC SCORE G ___P ___ ( __ __ __ __ )
( ) OVERWEIGHT ≥ 25 - ≤ 30 OD
LMP ___________________ ECG (result)
( ) OBESE I ≥ 30 - ≤ 35 MENARCHE ___________________ OS
( ) OBESE II ≥ 35 - ≤ 40 HBsAg (result) OU
( ) OBESE III ≥ 40 NSD C/S ____x ABORTION
PERTINENT PHYSICAL EXAMINATION FINDINGS:
FINAL DISPOSITION PHYSICAL HEALTH PROFILE
(Encircle)
P1 P3
P2 P4
____________________________________________________________
SIGNATURE OVER PRINTED NAME
C, MEDICAL-DENTAL BOARD