Dental
History
Vitals
PE
Dental
X-Ray
ECG
Psychological
Opthalmology
Laboratory
PE Details
Control IDnum
Date
Name
Package
Work Type
Land Based
Sea Farer
POEA License
Others
Vitals
Height
cm.
Weight
kgs.
BMI
Built
Temperature
°C
Blood Pressure
Pulse
beats/min
Respiration
breaths/min
Vaccination
Specialty
PHYSICAL EXAMINATION
Findings
TransDate
by
Skin:
Normal?
Yes
No
Head,Neck,Scalp
Yes
No
Eyes,External
Yes
No
Pupils
Yes
No
Ears
Yes
No
Nose,Sinuses
Yes
No
Mouth,Throat
Yes
No
Dental
Yes
No
Breast Exam
Yes
No
(to be administered by female doctor)
Lungs
Yes
No
Heart
Yes
No
Abdomen
Yes
No
Back
Yes
No
Anus/Rectum(DRE)
Yes
No
G-U system
Yes
No
Reflexes
Yes
No
Extremities
Yes
No
Neck L N.thyroid
Yes
No
Inguinals,Genitals
Yes
No
Hearing
AD 15/
AS 15/
Clarity of Speech
n/a
Adequate
Defective
Body Built
DENTAL
Findings
TransDate
by
Diagram...
Upper Teeth
-
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8
Lower Teeth
C - Dental caries
RF - Root Fragment
UN - Unerupted
MP - Impacted
M - Missing
X - Indicated for extraction
T.F. Temporary Filling
AM - Amalgam Filling
CM - Cement Filling
AD - Adhesive Compsite Filling
JC - Jacket Crown
MC - Metal Crown
IN - Inlay
AB - Abutmen
P - Pontec
C/V - dental caries with exposed vital pulp
C/NV - dental caries with exposed non vital pulp
BDC - broken down crown
RCt - root cancal treatment
S - silicate filling
Radiology
Findings
TransDate
by
PE Radiology Result
Remarks
Radiologist
PRC License
ECG
Findings
TransDate
by
Impression
Cardiologist
PRC License
PSYCHOLOGICAL
Findings
TransDate
by
Details...
For Further Evaluation
n/a
Adequately Adjusted Personality
OPTHALMOLOGY
Findings
TransDate
by
Far Vision Uncorrected
OD 20/
OS 20/
Near Vision Uncorrected
OD J/
OS J/
Far Vision Corrected
OD 20/
OS 20/
Near Vision Corrected
OD J/
OS J/
Color Vision
Adequate
Defective
LABORATORY
Findings
TransDate
by
URINALYSIS
Physical Examination
Puss Cells
/hpf
Color
Transparency
Reaction
Specific Gravity
Stool Examination
SY-Serological Test (VDRL)
Microscopic Examination
WBC
/hpf
RBC
/hpf
Epithelial Cells
Mucus Threads
Bacteria
Amorphous Phosphates
Amorphous Urates
Yeast Cells
Crystals
Casts
Hepatitis B Surface Antigen Test
Aids Clearance Test
RH
Drug and Alcohol Test
Chemical Examination
Urine Sugar
Urine Albumin
Others
Remarks
Medical Technologist
PRC License
Pathologist
PRC License
FECALYSIS
Color
Consistency
Blood:Gros
Urobilin
Mucus
Occult Blood
Bilirubin
Microscopic Examination
Ova
Amoeb
Remarks
WBC
/hpf
RBC
/hpf
COMPLETE BLOOD COUNT(CBC)
COMPLETE BLOOD COUNT (CBC)
Normal Value
Result
Hemoglobin
Hematocrit
RBC_Count
4.06 - 4.69
MCV
MCH
MCHC
318 - 364
WBC_Count
Segmenters
Lymphocytes
Monocytes
Eosinophils
Basophils
Blood_Type
Additional
LIPID PROFILE
BUA
FBS
Occult Blood
FBS (Manual Entry)
Normal Value
Result
BUA
Female = 0.15 - 0.35 mmol/L
Male = 0.21 - 0.42 mmol/L
FBS
3.89 - 5.5 mmol/L
Cholesterol
<220 mgs%
HDL
35-88 mgs%
LDL
66- 178 mg/dL
Triglycerides
<2.26 mmol/L
Risk_Factor
3.43
FOBT
Pap_Smear
Please see attached result