Muntinlupa Public Hospital

Civic Drive Filinvest Ave, Corporate Ave, Alabang, Muntinlupa, 1780 Metro Manila

MEDICAL CERTIFICATE

Name of Applicant: .......................................................................................................................

Gothel W. Bruha

Date of Birth: ................................................................................................................................

November 1, 1951

Past medical history (within five-year period before examination):

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General Examination (mark with cross)

Sight Hearing Teeth Heart Reflexes

Normal x x

Abnormal x x x

BWR (Bordet-Wasserman Reaction): 138>110 FW: 150>125

Blood Pressure: High EKG: 98<100 X-Ray Examination:

Haematologic Values:
Erythrocytes: 140<150 Leukocytes: 110>100 Count: 55

Tests of Lever Function: ALT: µkat/l S-Glucose: mmol/l

AST:
ALP: S-Bilirubin: µmol/l

Tests of Renal Function: Urea: mmol/l Na: mmol/l

Creatinine: µmol/l K:
Uric Acid: µmol/l Cl:

Cholesterol: mmol/l

Urine Analysis:
Protein: 6.6 g/dl Sugar: 77.3 g/dl Urobilinogen: 28.8 IU/L

Is applicant suffering from an infectious disease? No

Viral:
- Hepatitis:
- Human Immunodeficiency Virus (HIV):

Bacterial: No

Mycotic: No

Spirochetal: No
Protozoan: No

Metazoan: No

Is applicant suffering from disease of?

Skin, Connective Tissues or Bone: No

Bronchopulmonary System: No
Cardiovascular System: Yes
Digestive System: No
Kidneys: Yes
Liver and Biliary Tract: No
Blood and Blood-forming Organs: No
Metabolism: No
Endocrine System: No
Nervous and Neuromuscular System: No

Mental disorder: No
Allergic disorder: No

I confirm that the candidate is in (mark unequivocally):

excellent, good, rather good, rather poor, bad state of health, without any symptoms of infection
and I guarantee the accuracy of the information given above.

Signature: ................................................ Physician/Affiliation ................................................

Doo D. Little

Address: ................................................
Civic Drive, Filinvest Ave., Muntinlupa City Date: ................................................
February 18, 2019

To be signed by the applicant:

The undersigned declares that he/she has answered the above questions truthfully and to
the best of his/her ability.

In accordance with the Czech regulations the applicant is required to pass general medical
examination and blood tests in the Czech Republic.

Applicant’s signature: .......................................

Place: .............................................................. Date: ............................................................

Certificate

On the basis of a medical examination I certify that Mr./Mrs. ...................................................

born on .......................................................................... is in good health.

Date ...................... Doctor´s signature and stamp ..................................................................