DOH Accreditation No.: 13-064-14-MF-2

Call Us: (02) 844-1713
Welcome Guest!

Schedule an appointment:

Middle Initial
Birth Date (MM/DD/YYYY)
Civil Status
Contact No
Email Address

Place of Birth
Country of destination
Schedule Date

MEDICAL HISTORY - Have you been ever suffered from, been diagnosed, sought advice or treatment from a medical doctor on the following conditions:
Head or neck injury Other Lung Disorders Gynaecological Disorders
Frequent headaches High Blood Pressure Last Menstrual Period
Frequent Dizziness Heart Disease/Vascular/Chest Pain Kidney or Bladder Disorder
Fainting spells, fits or seizures or Other Neurological Disorders Rheumatic fever Back Injury / Joint Pain / Arthritis
Insomia or Sleep Disorders Diabetes Melllitus Genetic, Hereditary or Familial Disorders
Depression, Other Mental Disorders Other Endocrine Disorders (e.g. Goiter) Sexually Transmitted Disease
Eye Problems / Error of Refraction Cancer or tumor Tropical Diseases (e.g. Malaria, Typhoid Fever)
Deafness, Other Ear Disorders Blood Disorders Schistosomiasis
Nose or Throat Disorders Stomach Pain, Gastritis or Ulcer Asthma
Tuberculosis Other Abdominal Disorder Allergies
Operations Specify:
1. Have you ever been signed off as sick or repatriated from a jobsite overseas?
2. Have you ever been hospitalized?
3. Have you ever been declared unfit for work overseas?
4. Has your medical certificate ever been restricted or revoked?
5. Are you aware that you have any medical problem, disease or illness?
6. Do you feel healthy and fit to perform the duties of your designated position/occupations?
7. Are you allergic to any medication?
8. Are you taking any non-prescription or prescription medication? If yes, please list the medication(s) taken/being taken, and the purpose(s) and dosages(s):