page 1 of 2 Rev MER form 000002-2011 EXAMINING CLINIC : AVENTUS MANILA

MEDICAL EXAMINATION REPORT RCS # 584376

PATIENT INFORMATION. Complete this section PRINT IN CAPITAL LETTERS USING BLACK INK
DATE OF EXAMINATION: 11 9 2022 ANNUAL PHYSICAL EXAMINATION ✓ PRE-EMPLOYMENT
mm dd yy
NAME: ORDUÑA JOHN LORENZ GRAPILON DATE OF BIRTH 9/5/1987 Age 35 Sex MALE CS SINGLE
Last Name First Name Middle Name
ADDRESS: QUEZON CITY TELEPHONE NO.: 9055621890
COMPANY: PH GLOBAL JET EXPRESS INC OCCUPATION: ACCOUNT NUMBER: PEME
NOTE: It is advised that all required tests are completed for the timely evaluation of the medical examination report and release of results. Failure to do so may cause delay.
Present Illness: NONE Allergy: ✓ Food SHRIMP
Medication
Past Medical History
Asthma - Bronchial / Skin Head / Neck injury Neurologic disorders - fainting spells,
Cancer or Tumor Hypertension seizures, mental d/o
Endocrine disorders (Diabetes Mellitus, Thyroid D/o Kidney Disease ( Polycystic kidney, Lithiasis) ✓ Viral Infections (Chicken Pox, Measles)
ENT disorders (Ear, nose, Throat) Liver Disease (Hepatitis, Cirhosis, etc) ✓ Others LUNG DISEASE: PTB
Genito Urinary (STD, UTI) ✓ Lung disease (PTB, COPD) (10/2019); VIRAL
Medication/s Taken Dosage Frequency

Operations:
Immunization Hepatitis A Hepatitis B HPV vaccine Pre-announced vaccine Typhoid OTHERS: ANTI-
✓ MMR ✓ DPT Chicken pox ✓ Tetanus toxoid ✓ Others RABIES VACCINE,

Family History: Personal and Social History

✓ Asthma ✓ Diabetes mellitus Thyroid disease ✓ Smoking 20 sticks per day for 20 year/s
Blood Dyscrasia ✓ Heart Disease Tuberculosis ✓ Drinking bottle per shots per
Cancer ✓ Hypertension ✓ Remarks ASTHMA (FS); HEART OCC.
DISEASE (MS); DM II (FS); HPN (MS)

DO NOT FILL BELOW THIS LINE FOR MEDICAL EXAMINER ONLY.

Menstrual History: LMP PMP Duration Interval: Regular Irregular
Obstetrical history: G P ( - - - ) NSD CS 2ˆ Complications
Vital Signs Anthropometrics Visual Acuity
BP 1st 120 / 70 2nd / 3rd / Height 168 cm BMI 24.8 Right 20/20 Contact Lenses
PR 83 RR 20 Temp: 36.1 Weight 70 kg IBW 66.9 Left 20/60 Eye Glasses

PHYSICAL EXAMINATION
Findings - + Remarks
General appearance, body built ✓
Skin ✓
Head and Eyes ✓
Ears, Nose and Throat ✓
Neck ✓
Lungs ✓
Breast ✓
Chest ✓
Heart ✓
Abdomen ✓
Rectal WAIVED ✓ Waived/Refused
Genital WAIVED Patient's signature: (sgd)
Extremities ✓
Back ✓
Neurology ✓
Others ✓ TATTOOS (BOTH SIDES OF THE NECK, LEFT SIDE OF THE CHEST, UPPER BACK & BOTH FOREARMS)
(sgd) (sgd)
ORDUÑA, JOHN LORENZ GRAPILON FERDINAND SUATENGCO, M.D. Lic. No. 0063759
Signature of Patient Medical Examiner
TO MEDICAL EXAMINER : DO NOT WRITE BELOW THIS LINE, FOR MEDICAL EVALUATOR USE ONLY)
DIAGNOSTIC EXAMINATION
LABORATORY FINDINGS
Complete Blood Count NORMAL Blood Chemistry: N/A
Urinalysis NORMAL
Fecalysis NORMAL
ANCILLARY PROCEDURES
Chest X-ray PULMONARY NODULE AND MINIMAL HAZY OPACITIES IN THE RIGHT UPPER LUNG. WITH A PREVIOUS HISTORY OF PTB, AN INFLAMMATORY PROCESS IS P
ECG N/A
Pap Smear N/A
Others DT: 2 PANEL = NEGATIVE;
Note: Medical evaluation results are based on the physical examination and disclosure of patient's pertinent health history
and findings on the diagnostic results available at the time of examination.
AUTHORIZATION TO DISCLOSE
FOR PROCEDURES AVAILED USING MY HMO PROVIDER OR FOR EMPLOYMENT RELATED MATTERS SUCH AS APE/PEME/DRUG TEST, I HEREBY AUTHORIZE AVENTUS MEDICAL CARE, INC. TO
RELEASE TO MY EMPLOYER, POTENTIAL EMPLOYER REQUESTING FOR THE TESTS, OR HMO PROVIDER, WHICHEVER IS APPLICALBE, ALL RELATED MEDICAL RECORDS AND DOCUMENTS
DERIVED AND/OR GENERATED FROM MY AVAILMENT FROM AVENTUS OF LABORATORY OR MEDICAL CONSULTATION SERVICES.
I UNDERSTAND THAT AVENTUS MEDICAL CARE, INC., INCLUDING ITS DIRECTORS, OFFICERS, STOCKHOLDERS, EMPLOYEES, CONSULTANTS AND DOCTORS SHALL BE FREE FROM ANY AND
ALL LIABILITY RELATING TO THIS DISCLOSURE.
THIS I AUTHORIZE OUT OF MY OWN FREE WILL WITHOUT FORCE, INTIMIDATION NOR VIOLENCE UPON ME.

(sgd)
ORDUÑA, JOHN LORENZ GRAPILON
This is a system generated result. NAME & SIGNATURE OF PATIENT
 page 2 of 2 MEDICAL EXAMINATION REPORT RCS # 584376
DATE OF
NAME: ORDUÑA JOHN LORENZ GRAPILON BIRTH
9/5/1987 Age 35 Sex MALE CS SINGLE
Last Name Firstname Middlename
AUDIOMETRY
AUDIOMETRY: 125 250 500 1000 2000 4000 8000 REMARKS
Right
Left
DENTAL EXAMINATION
FINDINGS

RECOMMENDATION

Dental Examiner

Date

CLINIC ASSESSMENT
1.) OVERWEIGHT (BMI = 24.80)
2.) ERROR OF REFRACTION, LEFT EYE

RECOMMENDATION
1.) DECREASE BODY WEIGHT. ADVISE LOW CALORIE DIET. ENGAGE IN MODERATE EXERCISE FOR AT LEAST 30 MINUTES A DAY. LIFESTYLE CHANGE ENCOURAGED. CONSULT PRIMARY
CARE / COMPANY PHYSICIAN FOR NUTRITIONAL / WEIGHT MANAGEMENT.
2.) CONSULT PRIMARY CARE/ COMPANY PHYSICIAN FOR POSSIBLE OPHTHALMOLOGY REFERRAL.
3.) FOR PULMONOLOGIST CLEARANCE REGARDING CHEST X-RAY FINDINGS.
4.) LIFESTYLE MODIFICATION AND REGULAR BLOOD PRESSURE MONITORING.
5.) ADVISE SMOKING CESSATION.

(sgd) (sgd)
ORDUÑA, JOHN LORENZ GRAPILON WINDALE ROSS C. PAYALES, M.D. Lic. No. 0138145
Signature of Patient Medical Evaluator

FOR PRE-EMPLOYMENT FITNESS CERTIFICATION

Class A - Physically fit for any work. Class D - Unfit or unsafe for any type of employment.
Class B - Physically underdeveloped or with correctible defects but otherwise fit to work. ✓ Pending
Class C - employable but owing to certain impairments or conditions which require special placement PULMONOLOGIST CLEARANCE REGARDING CHEST X-
or limited duty in a specified or selected assignment requiring follow-up treatment/periodic evaluation. RAY FINDINGS
( * Disclaimer: Employment at the risk and discretion of the client * )

Date Re-evaluation (for completion/clearance, if necessary)

Re-Classification: Class A Class B

Class C Class D
Note: Medical evaluation results are based on the physical examination and disclosure of patient's pertinent health history and findings on the
diagnostics results available at the time of examination.

This is a system generated result.