Medical Checklist (003) - Lance Cruz PDF

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Download Medical Checklist (003) - Lance Cruz PDF

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27F Net Lima Building, 5th Avenue corner 26th Street Bonifacio Global City, Taguig City, 1634 Philippines Telephone Number: (+632) 866-2145

HEAD OFFICE

Good day! As part of our Medical Clearance, we have forwarded your results to our company physician and with that we would like to verify if you are experiencing any of the following symptoms listed below:  If you are experiencing the symptom X

If you do not experience the symptom

X

Chest pain (may spread to the back, neck, arms and/or jaw)

X

Dizzines

X

Nausea, vomitting

X

Rapid or irregular heartbeats

X

Shortness of breath

X

Some people may exhibit anxiety, indigestion and/or heartburn( some women may present with these as their predominant symptoms instead of chest pain

X

Weakness

X

Malaise

X

Others ___________________

I acknowledge that I have no other medical symptoms in addition to what I have declared above.

___LANCE MAWRENCE B. CRUZ___ Name & Signature

27F Net Lima Building, 5th Avenue corner 26th Street Bonifacio Global City, Taguig City, 1634 Philippines Telephone Number: (+632) 866-2145

HEAD OFFICE

________JUNE 5,2019___________ Date...