STUDENT’S HEALTH RECORD

Last Name: First Name: Middle Name: Age: Sex:

Male Female

Address: Mobile No.

Birthday (m/d/y): Birthplace: Marital Status: Religion: Nationality:

Husband/ Wife’s Name: Father’s Full Name: Mother’s Maiden Name:

In case of emergency, please notify: Relation:

Address: Mobile No.

Instruction: Put cross (X) on the corresponding boxes of your answer

PAST MEDICAL HISTORY FAMILY HISTORY

Asthma

Diabetes Mellitus

Epilepsy

Fainting Spells/ Seizures

Heart Disease:[Please specify]

Hematopoietic Disorders: [Please specify]

Hypertension

Gastrointestinal Disorders: [Please specify]

Kidney Disorders: [Please specify]

Mental Health Disorders: [Please specify]

Migraine

Thyroid Disease: [Please specify]

Tuberculosis

Acid Related Diseases

Childhood related diseases (Chicken pox. Measles,

German measles)

Cancer (please specify)

(for female only)

Menstrual History: Menarche_______________ Interval ______________ Duration ______________
Amount_______________ Dysmenorrhoea _________________

1
 PREVIOUS OPERATIONS ALLERGIES

[List all previous operations including date and place]

IMMUNIZATION HISTORY
VACCINE DATE DOSES

BCG

TETANUS

HEPATITIS A

HEPATITIS B

VARICELLA

MMR

FLU

In compliance to RA 10173 (Data Privacy Act of 2012), the information given to SLMCCM-WHQM- College
Health Clinic were all confidential and only to be used when there is a need in health issues, problems or
concerns. Therefore, I am aware and giving my consent to SLMCCM-WHQM College Health Clinic on the
collected data and information submitted during enrolment and the other forms that will be included in my
Students File Record.

_____________________________
Signature over printed name