chest x-ray result physical examination
TRANSCRIPT
NOTE: THIS CLINIC OBSERVES “DATA PRIVACY ACT OF 2012”
GRADING & RECOMMENDATION
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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
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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)