Republic of the Philippines
NATIONAL POLICE COMMISSION
PHILIPPINE NATIONAL POLICE
REGIONAL MEDICAL AND DENTAL UNIT 11
Camp Quintin M. Merecido, Catitipan, Davao City
Rank Last Name FirstName M.I Age/Sex
Unit Badge Number Contact Number Date of Birth
Height (CM) Weight Waistline BMI Classification BP
PNP ACCEPTABLE BMI CLASSIFICATION Wt to lose
<-29 YO 30-34 YO 35-39 40-44 YO 45-50 Y.O ->50YO BMI CLASSIFICATION
YO
17-18.4 UNDERWEIGHT Profile
P1 P2 P3 P4
18.5-24.9 NORMAL
25.6-29.9 27.4-29.9 28.5- 29.9 ---------- OVERWEIGHT ECG RESULT
29.9
30.0-34.9 OBESE 1
35-39.9 OBESE II
>40 OBESE 111
------------------------------------TO BE FILLED UP BY MEDICAL OFFICER----------------------------------------------------
MEDICAL IMPRESSION/ASSESSMENT: HEALTH CLEARANCE
GO ( ) NO GO ( ) DEFFERED ( )
PP
( ) Advised healthy lifestyle and diet modification REASONS:
RECOMMENDATIONS: SEEN AND EXAMINED BY:
( ) FOR WEIGHT MANAGEMENT PROGRAM
( ) FOR MEDICAL EVALUATION AND TREATMENT
REPORT TO RHS ON _________________________
IMPORTANT: PLEASE BRING THIS DURING ACTUAL PFT
MEDICAL OFFICER
Republic of the Philippines
NATIONAL POLICE COMMISSION
PHILIPPINE NATIONAL POLICE
REGIONAL MEDICAL AND DENTAL UNIT 11
Camp Quintin M. Merecido, Catitipan, Davao City
Rank Last Name FirstName M.I Age/Sex
Unit Badge Number Contact Number Date of Birth
Height (CM) Weight Waistline BMI Classification BP
PNP ACCEPTABLE BMI CLASSIFICATION Wt to lose
<-29 YO 30-34 YO 35-39 40-44 YO 45-50 Y.O ->50YO BMI CLASSIFICATION
YO
17-18.4 UNDERWEIGHT Profile
P1 P2 P3 P4
18.5-24.9 NORMAL
25.6-29.9 27.4-29.9 28.5- 29.9 ---------- OVERWEIGHT ECG RESULT
29.9
30.0-34.9 OBESE 1
35-39.9 OBESE II
>40 OBESE 111
------------------------------------TO BE FILLED UP BY MEDICAL OFFICER----------------------------------------------------
MEDICAL IMPRESSION/ASSESSMENT: HEALTH CLEARANCE
GO ( ) NO GO ( ) DEFFERED ( )
PP
( ) Advised healthy lifestyle and diet modification REASONS:
RECOMMENDATIONS: SEEN AND EXAMINED BY:
( ) FOR WEIGHT MANAGEMENT PROGRAM
( ) FOR MEDICAL EVALUATION AND TREATMENT
REPORT TO RHS ON _________________________
IMPORTANT: PLEASE BRING THIS DURING ACTUAL PFT
MEDICAL OFFICER
Date:
I HEREBY CERTIFY that is my OWN ECG result, such ECG Examination is conducted upon myself. I hold
myself for perjury, falsehood, misinterpretation or omission or act of dishonesty. I attest to the truthfulness of
this certification legal and administrative consequences therefore if ever statements above are wanting in truth
and substance.
___________________________
Signature over printed name
(PNP Personnel)
Date:
I HEREBY CERTIFY that is my OWN ECG result, such ECG Examination is conducted upon myself. I hold
myself for perjury, falsehood, misinterpretation or omission or act of dishonesty. I attest to the truthfulness of
this certification legal and administrative consequences therefore if ever statements above are wanting in truth
and substance.
___________________________
Signature over printed name
(PNP Personnel)
