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Medical Form

PRA form for medical record

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: MEDICAL EXAMINATION FOR SRRV APPLICANTS
Republic of the Philippines

SRRV APPLICATION NO.: ______

DEPARTMENT OF TOURISM

PHILIPPINE RETIREMENT AUTHORITY
29/F Citibank Tower, Paseo de Roxas, Makati City, 1227 Philippines
Tel. No.: +632 8481412, FAX: +632 8481411, Email: inquiry@pra.gov.ph; Website: www.pra.gov.ph

PLACE:

DATE

Place passport size photo here
not taken more than 6 months ago

As requested by the Philippine Retirement Authority

I certify that I was examined on the date stated above

MEDICAL CERTIFICATE FOR SRRV APPLICANTS

Name:

Age:

Gender:

Nationality:

Under the Philippine Immigration Regulation, the applicant should be classified as follows:
(Encircle the appropriate class)
DANGEROUS AND CONTAGIOUS DISEASE
Chancroid, Gonorrhea, Granuloma Inquinale, Leprosy (Infectious),
Lymphogranuloma Venareum, Syphilis (Infectious Stage), and
Tuberculosis (Active)
SERIOUS MENTAL DISORDER
Mental Retardation (Mental Deficiency), Insanity, Previous Occurrence
of one or more attacks of Isanity, Anti-Social Personality, Mental
Defects, Epilepsy, Sexual Deviation, Narcotic Drug Addiction, Chronic
Alcoholism
PHYSICAL DEFECTS AND DISORDER

Class A

Class B

Physical defects, disease or disability serious in degree or permanent in
nature that impairs the ability to earn a living as to make them likely to
be a public charge
MINOR CONDITIONS

Class C

MEDICAL

RECORD

1. Pertinent Medical History:
2. Significant Physical Examination:
3. Chest X-ray report: (for ages 11 years & above)
Present recent x-ray film (14x17 inches)
4. Laboratory examination: (attach laboratory reports)
a.
b.
c.
d.
(

Blood Serology: RPR/VDRL (Ages: 15 yrs. And above)
Urinalysis: (Age: 1 yr. and above)
Stool (Ova and Parasite) : (Ages: 1 yr. and above)
Other examination(s), if necessary
)

Not physically and mentally defective or diseased

EXAMINING PHYSICIAN / License No.:

SIGNATURE

__________________________________
NAME OF CLINIC OR HOSPITAL:

_____________________

_____________

ADDRESS:

__________________________________

PRA-CR-FORM-0012

DATE

ISSUE NO: 0001

__________________________________

ISSUE DATE: JANUARY 2017
 
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