NOTE: THIS CLINIC OBSERVES “DATA PRIVACY ACT OF 2012”

GRADING & RECOMMENDATION

A ______________________________________________

B ______________________________________________

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NOTES:________________________________________

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Panel Physician’s Name

DR. ALBA DR. BARUIZ

DR. CASIA DR. TAN

DR. SERMON DR. NOBLEZA

Checked by MD Submitted Date: _________________

Checked by ML Submitted by: _________________

Instructed/ CLEARED TO GO MD ML

NHSI DAVAO

Medical Evaluation

PASSPORT #:_____________________ TI:__________ TO:________

DOB: ________________ NO Passport

DOE:__________________ Other ID #:___________________

AGE:______ SEX: Male Female Unknown Indeterminate

CIVIL STATUS: Single Married Widow/er Separated

HAP/IME/NZER Number:

Date:

NAME: Surname First name MN

ADDRESS:

Contact #:

1.

2.

Urgent

Deadline:

____________

ADDITIONAL LABORATORY TEST Serum Creatinine ECG HBsag Ferritin Repeat Urinalysis TST/IGRA______ Repeat CBC Other Test:_____

SPECIAL’S REPORT CARDIOLOGIST PEDIATRICIAN ENDOCRINOLOGIST OBYGNE

NEPHROLOGIST OTHERS______ GASTROENTEROLOGIST

PULMONOLOGIST

LABORATORIES

PE HCV

Urinalysis Serum Crea

Chest Xray PA/PAL Hb1Ac

HIV CBC

VDRL Chest ALV

Hbsag Chest Spot

U/A #_______ DS M1 M 2 N N N AB AB AB

_____ _____ _____

AUS P D

CA T W T S D

NZ F____ TB NON TB

H:_______ W:______HC: _______

BP: 1._________ BP: 2. _________

BP: 3.________ BP: 4. _________

VA: Left:_______ Right:________

ROR Present Absent

MEDICATIONS 1.

2.

3.

4.

5.

History of AB CXR Findings/Yr_________

With previous CXR Images/YR_________

Previous CXR _______ Normal Abnormal (Last 6months) Year History of Chest Clinic Investigation:

Year ___

Tx/Duration ______ DOTS PRIVATE

SPUTUM EXAM: POSITIVE NEGATIVE

PATIENT’S HX

Exposure to TB

Household/Relative/YR HX of travel Abroad_____

History of PTB/ YR______ HX of Autism/ ADHD

History of Primary Complex Immunization MMR POLIO

CANCER/YR________ HX of Hosp

HPN-YR__________ A:_________

DM-YR_________

*this field is required for woman*

PREGNANT: YES NO

Last Menstruation Period: _____________________

PE FINDINGS

CLAD

AB LUNG FINDINGS

DEV NOT AT PAR W/ AGE

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Physical Examination

Normal

Abnormal

________________________

________________________

________________________

________________________

_____

CHEST X-ray Result

Normal Abnormal

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Current Do you have? Tick what

applies:

cough

fever

sore Throat

headache

not feeling well

Have you been diagnosed to have Covid 19

infection or had a positive RT-PCR test? Yes No

Covid-19 Vaccine Fully Vaccinated: Not Fully Vaccinated: Not Vaccinated:

NOTE: THIS CLINIC OBSERVES “DATA PRIVACY ACT OF 2012”

NATIONWIDE HEALTH SYSTEMS DAVAO, INC Suite 4, Pelicano Bldg., Ecoland Phase 1,

36 Quimpo Blvrd.,

8000 Davao City

GENERAL INFORMATION SHEET (For Applicants) PERSONAL DATA AUSTRALIA CANADA NEW ZEALAND

Surname/Last Name: ________________________________ HAP/IME/NZER#_________________

Given/First Name: ___________________________________

Middle Name: ______________________________________

AGE: _______________ Gender: Male Female

Date of Birth: ____________________________

CIVIL STATUS: Single Married Widow Divorce/Separated

Email Address: (at least one): ______________________________________________________

Past Medical History of Pulmonary Tuberculosis

Yes (Year) __________ No

If Yes, please bring previous films (preferably digital – dicom format save in CD) and

Certificate of treatment.

DECLARATION BY EXAMINEE

I declare that this is my first time to have Immigration Medical Examination (IME). I had my last Medical on (date) ____________________ at ____________________________. I declare that the information given above is TRUE and CORRECT.

___________________________________________________________

Signature of Applicant over Printed Name

(If minor, Guardian can sign in behalf of the Applicant)