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    SRRV Medical Form

    Uploaded by

    Jocelyn Co
    This document is a medical examination form for applicants to the Philippine Retirement Visa (SRRV). It requests personal information from the applicant such as name, age, gender, and nationality. It also requires a medical professional to examine the applicant and classify them into one of four health classes: dangerous and contagious diseases, serious mental disorders, physical defects and disorders, or not physically and mentally defective. The medical professional must provide pertinent medical history, physical examination results, chest x-ray report, and laboratory test results. They then sign and date the completed form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    SRRV Medical Form

    Uploaded by

    Jocelyn Co
    239 views1 page
    This document is a medical examination form for applicants to the Philippine Retirement Visa (SRRV). It requests personal information from the applicant such as name, age, gender, and nationality. It also requires a medical professional to examine the applicant and classify them into one of four health classes: dangerous and contagious diseases, serious mental disorders, physical defects and disorders, or not physically and mentally defective. The medical professional must provide pertinent medical history, physical examination results, chest x-ray report, and laboratory test results. They then sign and date the completed form.

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    SRRV Medical form

    Original Title

    SRRV Medical form

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    This document is a medical examination form for applicants to the Philippine Retirement Visa (SRRV). It requests personal information from the applicant such as name, age, gender, and nationality. It also requires a medical professional to examine the applicant and classify them into one of four health classes: dangerous and contagious diseases, serious mental disorders, physical defects and disorders, or not physically and mentally defective. The medical professional must provide pertinent medical history, physical examination results, chest x-ray report, and laboratory test results. They then sign and date the completed form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    239 views1 page

    SRRV Medical Form

    Uploaded by

    Jocelyn Co
    This document is a medical examination form for applicants to the Philippine Retirement Visa (SRRV). It requests personal information from the applicant such as name, age, gender, and nationality. It also requires a medical professional to examine the applicant and classify them into one of four health classes: dangerous and contagious diseases, serious mental disorders, physical defects and disorders, or not physically and mentally defective. The medical professional must provide pertinent medical history, physical examination results, chest x-ray report, and laboratory test results. They then sign and date the completed form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    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.:


    __________________________________
    NAME OF CLINIC OR HOSPITAL:
    __________________________________

    SIGNATURE

    DATE

    _____________________

    _____________

    ADDRESS:
    __________________________________

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