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HEALTH SCREENING/FPE FORM

I. CLIENT PROFILE

Walk-in Type
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INDIVIDUAL HEALTH PROFILE

Age
Sex:
Client Type:

II. REVIEW OF SYSTEMS

2. Do you experience any of the following: fever, cough, colds, or headache?
3. Do you experience any of the following: unexplained change in weight, loss of appetite, change in bowel movement, or abdominal pain?
4. Do you experience any of the following: chest pain or difficulty in breathing?
5. Do you experience any of the following: frequent urination, frequent eating, frequent intake of fluids, smoking and drinking alcohol?
6. Do you experience any of the following: pain or discomfort on urination or frequency of urination?

If the answer is yes to Questions 1-6, the beneficiary needs to consult a doctor.

III. PERTINENT PHYSICAL EXAMINATION FINDINGS

20 /

20 /

Blood Type (as available)
General Survey:

IV. LABORATORY RESULTS

COMPLETE BLOOD COUNT

URINALYSIS

XRAY

12-L ECG

CHEMISTRY

OTHER TESTS

V. PHARMACY

FOR COMMUNICABLE DISEASES

FOR NON-COMMUNICABLE DISEASES

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