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HEALTH SCREENING/FPE FORM
I. CLIENT PROFILE
INDIVIDUAL HEALTH PROFILE
Last name:
Health Screening Date:
First name:
PhilHealth Identification Number:
Middle Name:
Extension Name:
Date of Birth (mm/dd/yyyy):
II. LABORATORY RESULTS
COMPLETE BLOOD COUNT
WBC count
Lymphocytes (%)
Mid-Cells (%)
Granulocytes (%)
RBC count
Hematocrit
MCV
MCH
MCHC
Platelet count
Hemoglobin
Remarks
URINALYSIS
Color
Transparency
Specific Gravity
pH
Protein
Sugar
RBC
Pus Cells
Epithelial Cells
Crystals
XRAY
Examination Name
Findings
12-L ECG
Findings
CHEMISTRY
FBS
Cholesterol
Triglyceride
HDL
LDL
Uric Acid
AST
ALT
Crea
BUN
VLDL
OTHER TESTS
HbA1c
OGTT
Fecalysis
FOBT
Pap Smear
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