Page 3 6 MHR PRESCREEN QUESTIONNAIRE
Page 3 6 MHR PRESCREEN QUESTIONNAIRE
Page 3 6 MHR PRESCREEN QUESTIONNAIRE
2012-01
LAST NAME FIRST NAME MIDDLE NAME QUALIFIER AGE SEX CIVIL STATUS
INSTRUCTION: The instructions contained hereto and in the other medical forms are pertinent and vital. They shall be part of the personnel’s medical records. The information
you will give shall constitute an official statement. They are to be filled-up properly, honestly and with outmost integrity. If you are accepted into the PNP
based on a false statement herein you can be recommended for summary dismissal proceedings in the future.
PLEASE CHECK AND WRITE YOUR ANSWERS ON THIS QUESTINNAIRE ON THE SPACE PROVIDED, may use additional sheet/s if necessary.
STATE OF HEALTH
Stable w/
1. FAMILY MEMBERS NAME DATE OF BIRTH known Seriously If deceased
Good please indicate
medical ill cause of death
condition/s
a. FATHER’S NAME
b. MOTHER’S NAME
c. SIBLINGS
d. SPOUSE’S NAME
e. CHILDREN’S NAME
3. FAMILY MEDICAL HISTORY
a. Have anyone in your family suffered from the following:
CONDITIONS YES NO RELATIONSHIP CONDITIONS YES NO RELATIONSHIP
Diabetes Hepatitis
Stroke Kidney Disease
Heart Disease Leukemia/Blood Cancers
High Blood Pressure Bleeding Disorders
Asthma Mental Disorder
Pulmonary Tuberculosis Drinking Problem
Goiter/Thyroid Disease Smoking Problem
b. Do you have any family member who died of heart disease? ڤYES ڤNO
If YES, indicate relationship and age at the time of death ______________________________________________________________________
Left-handed
Usual Physical Activities/Sports Played (how often)
6. VACCINATION HISTORY
Vaccine YES NO When No. of doses Vaccine YES NO When No. of doses
Hepatitis A Typhoid
7. MEDICATION HISTORY
a. Current Medications you are taking if there are any: b. Allergies to Medications, drugs or food, if there are any:
8. PAST MEDICAL HISTORY, HOSPITALIZATION & SURGERY ()If YES, please describe in the separate portion)
Have you ever had or do you now have the following: YES NO Have you ever had or do you now have the following: YES NO
1. Asthma, wheezing, or inhaler use 35. Epilepsy, fits, seizures, or convulsions
2. Tuberculosis 36. Sleepwalking
3. Collapsed lung or other lung condition 37. Fainting spells or passing out
4. Pneumonia 38. Bed wetting at age 12
5. Whooping cough 39. Heat Exhaustion
6. Diptheria 40. Absence or disturbance of the sense of smell
7. Anemia 41. Recurrent nose bleeding
8. Rheumatic Fever 42. Detached retina or surgery for a detached retina
9. Malaria 43. Wear contact lenses
10. Chicken Pox 44. Night blindness
11. Typhoid Fever 45. Any other eye condition, injury or surgery
12. Measles 46. Double vision
13. Mumps 47. Perforated ear drum or tubes in ear drum/s
14. Passing out of worms (parasitic infections) 48. Recurrent ear infection
15. Ulcer 49. Frequent or severe headaches
16. Hepatitis A or B 50. Recurrent neck or back pain
17. Jaundice (yellow discoloration of the skin and eyes) 51. Arthritis or frequent joint pains
18. Anorexia or other eating disorders 52. Fracture in any part of the body
19. Intestinal obstruction (locked bowels) 53. Pain or swelling at the site of an old fracture
20. Gall bladder disease or gall stones 54. Swelling of joints
21. Kidney Disease, including kidney stones 55. Lower extremity weakness
22. Sexually-Transmitted Infections 56. Paralysis of any part of the body
23. Recurrent Urinary Tract Infections 57. Used any form of body support or braces
24. Missing a kidney 58. Donated blood
25. (Females only) Dysmenorrhea 59. Received blood transfusion
26. (Males only) Missing a testicle, testicular implant, or 60. Eye surgery, including radial keratotomy, lens
undescended testicle implant or other eye surgery to improve your vision
27. Goiter or thyroid disease or with thyroid 61. Ear surgery, to include repair of perforated ear
medications drum, hearing loss or need/use a hearing aid
28. High blood sugar (diabetes) or with diabetes 62. Head injury, including skull fracture, resulting in
medications concussion, loss of consciousness, headaches, etc.
29. High blood pressure or with hypertension 63. Dislocated joint, including knee, hip, shoulder,
medications elbow, ankle or other joint
30. Irregular heartbeat, including abnormally rapid or 64. Broken bone requiring surgery to repair (w/ or w/o
slow heart rates pins, plates, screws or other metal fixation devices)
31. Heart murmur, valve problem or mitral valve 65. Surgery to remove a portion of the intestine (other
prolapse than the appendix)
66. Any illnesses, surgery, or hospitalization not listed
32. Discharged from military service for medical reasons
above
33. Been rejected for military service (temporary or 67. Evaluation, treatment, or hospitalization for alcohol
permanent) for medical or other reasons abuse, dependence, or addiction
34. Seen a psychiatrist, psychologist, social worker, 68. Evaluation, treatment, or hospitalization for
counselor or other professional for any reason substance use, abuse, addiction or dependence
(inpatient or outpatient) (including illegal drugs, prescription medications)
Describe in detail every YES answer, including how it was known, treatment done, etc.
9. REVIEW OF SYSTEMS
Have YOU had problems with any of the following within the past year?
I certify that the above information are true and correct to the best of my knowledge. I understand that failure to disclose pertinent
personal medical information may affect the assessment and evaluation of any medical officer to my physical fitness to perform my duties
and functions.
I hold myself liable for perjury, falsehood, misrepresentation or omission, or act of dishonesty, if there is willful failure to disclose
pertinent medical information. I attest to the truthfulness of this undertaking and submit to the legal and administrative consequences
thereof if ever the statements above are wanting in truth and substance.
_____________________ ___________________________________
Date Signature Over Printed Name
Applicant
EVALUATOR:
________________________________________
Signature Over Printed Name
MEDICAL OFFICER