NAME OF HOSPITAL:

Address:

PERMANENT HEALTH RECORD

HOSPITAL RECORD NUMBER

NAME
Age Birthday Sex Civil Status Classification
Home Address Religion Contact No.
Father Occupation Contact No.
Mother Occupation Contact No.
Heredofamilial disease present among family members
Personal history
Surgical Operation(s): Date(s) Operated
Disability:
Allergies: Food(s)
Medications/Drugs
Present medical problem (s)
******** For Females only
First day of Last menstruation Frequency Regular (every month )
Have you ever been pregnant No Yes If yes, how many times?

I hereby certify under the penalty of perjury that all my statements above are true and correct to the best of my knowledge. I consent
that the University Hospital may utilize my information as required by other related CMU-units and governments agencies for moral and
legal purposes.

______________________________ _____________________________________________
Signature Over Printed Name of student Signature over printed name of parent/relative/guardian

Vital Signs
BP mm/Hg HR bpm RR cpm T C Wt. kgs.
Eye Examination
Snellens R L Ishihara R L

Date / Time History * Physical examination * Laboratory results Diagnosis Treatment * Recommendation