Republic of the Philippines

Western Philippines University A STRONG PARTNER FOR SUSTAINABLE DEVELOPMENT

HEALTH SERVICES

STUDENT HEALTH RECORD

Instructions:
1. This form is to be filled out by the enrollee prior to seeing the physician and dentist.
2. Please provide necessary information by filling out all blanks and putting check [] in the box. Write legibly.

Informed Consent

I, ______________________________________, _____ years old, accept and

(Name of Enrollee) (age)
understand that I am required to undergo a physical examination to determine my
2x2 ID fitness and well-being as a student. I fully understand that the result will be held as
picture confidential medical records and will be used by the University for my care and
treatment. My health information cannot be released to third person except with my
consent or unless the disclosure of the information University for a period 10years from
examination or health visit.

Signature: __________________________

In case of emergency, please contact:

OR No.: __________________ Name: _______________________________ Relation: ___________
Date Issued: _______________ Address: ________________________________________________
Course: __________________ Contact Number: __________________________________________

I. PERSONAL INFORMATION

Name: _________________________ _________________________ ________________________

(Last Name) (First Name) (Middle Name)

Age: ____ years old Sex: [ ] Male [ ] Female Civil Status: [ ] Single [ ] Married Blood Type: _______
Date of Birth: ___________________________________ Religion: ________________________________
Birth Place: ____________________________________ Contact Number: __________________________
Permanent Address: _____________________________________________________________________
Address while in school: __________________________________________________________________
Name of Guardian / Spouse: ________________________ Contact Number: __________________________

Parents: FATHER MOTHER

Name: _____________________________ _________________________________
Date of Birth: _____________________________ _________________________________
Educational Attainment: _____________________________ _________________________________
Occupation: _____________________________ _________________________________
Contact Number: _____________________________ _________________________________

II. MEDICAL HISTORY

Previous Illness: Yes No Yes No Yes No
Influenza (trangkaso) [ ] [ ] Asthma (hika) [ ] [ ] Dengue fever [ ] [ ]
Cough / colds (ubo / sipon) [ ] [ ] Tuberculosis (TB) [ ] [ ] Malaria [ ] [ ]
Tonsilitis [ ] [ ] Pneumonia (pulmonya) [ ] [ ] Typhoid fever [ ] [ ]
Chicken pox (bulutong tubig) [ ] [ ] Convulsion / epilepsy [ ] [ ] UTI(Urinary Tract Infection) [ ] [ ]
Measles (tigdas) [ ] [ ] Heart disease [ ] [ ] Others: ___________ [ ] [ ]

Immunization:
[ ] BCG [ ] DPT [ ] PCV [ ] Anti-rabies
[ ] Hepatitis B [ ] OPV [ ] MMR [ ] Influenza vaccine
[ ] Pentavalent [ ] Inactivated polio [ ] Tetanus toxoid [ ] Others: __________

Medicines: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional)
that you are currently taking. _______________________________________________________________
___________________________________________________________________________________
Do you have any allergies? [ ] Yes [ ] No
If yes, please identify specific allergy: [ ] Food [ ] Medicines [ ] Pollens [ ] Stinging insects
Do you have disabilities: [ ] Yes [ ] No If yes, identify the type of disability: ___________________
Cause of disabilities: [ ] At birth [ ] Disease [ ] Accident / trauma (date: _______)[ ] others:_________
Previous hospitalization: [ ] Yes [ ] None If yes, specify: __________________________________
Surgery / Operation: [ ] Yes [ ] None If yes, specify: __________________________________
Accident / other injuries: [ ] Yes [ ] None If yes, specify: __________________________________

Family History:
[ ] Diabetes [ ] Heart disease [ ] Asthma [ ] Cancer [ ] Allergy
[ ] Hypertension [ ] Kidney disease [ ] Epilepsy [ ] Mental illness [ ] Others: _________

WPU-QSF-HSD-05 Rev.03 (07.06.21)

 Republic of the Philippines
Western Philippines University A STRONG PARTNER FOR SUSTAINABLE DEVELOPMENT

HEALTH SERVICES

Pubertal History: (Pagbibinata o pagdadalaga)

For Male Only: How old are you when you had: For female only: How old are you when you had:
A. Genital enlargement: _______ A. Menarche (First menstrual period? )________________
B. Growth of pubic hair: _______ B. Breast enlargement: ______C. Growth of pubic hair :_____
How many periods have you had in the last 12 months? ___________
Last menstrual period (LMP): ____________________________
OB Gyne History: ___( bilang ng anak) (G__P__) ( __,__,__,__,)
III. PHYSICAL EXAMINATION
Body Mass Index (BMI): Vital Signs: Visual Acuity:
Height: _______ m Temperature: _________ oC Right: ___________
Weight: _______ kg Pulse Rate: _________ bpm Left: ___________
BMI: weight(kg) _______ Respiratory Rate: _________ cpm Corrected: [ ] Yes [ ] No
Height( m x m ) O2 Saturation: _________ %SPO2 Remarks: ___________
Interpretation: _______ Blood Pressure: _________ mmHg ___________

Medical Examination: Normal Abnormal Findings

General Appearance
Eyes / ears / nose / throat
Lymph nodes
Heart / pulse
Lungs
Breast
Abdomen
Genitourinary (genitalia)
Skin
Musculoskeletal
Neurologic

Findings / Assessment Summary: ________________________________________________________

___________________________________________________________________________________
___________________________________________________________________________________.
Recommendations: ___________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________.
I have examined the above-mentioned enrollee and completed the student health record. The enrollee does not present apparent
clinical contraindications to enroll in the Western Philippines University as outlined above.

Name of Physician: ____________________________________ Date Examined: ______________________

Signature of Physician: __________________________________ License Number: _____________________

IV. DENTAL ASSESSMENT: (information to be filled out by the authorized personnel)

[ ] Good oral hygiene
[ ] Presence of calcular deposits
UPPER RIGHT UPPER LEFT
[ ] Gingivitis 8 7 6 5 4 3 2 1 With caries 1 2 3 4 5 6 7 8
[ ] Pyorrhetic 8 7 6 5 4 3 2 1 Amalgam 1 2 3 4 5 6 7 8
[ ] Clotting disorders 8 7 6 5 4 3 2 1 Other resto mat 1 2 3 4 5 6 7 8
[ ] Wearing Hawley’s retainers 8 7 6 5 4 3 2 1 Pontic 1 2 3 4 5 6 7 8
[ ] Denture wearer up 8 7 6 5 4 3 2 1 Missing 1 2 3 4 5 6 7 8
[ ] Denture wearer down 8 7 6 5 4 3 2 1 RF 1 2 3 4 5 6 7 8
[ ] With ortho braces up 8 7 6 5 4 3 2 1 Unerrupted 1 2 3 4 5 6 7 8
[ ] With ortho braces down 8 7 6 5 4 3 2 1 For exo 1 2 3 4 5 6 7 8
[ ] Others: __________________ 8 7 6 5 4 3 2 1 TF 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 Abutment 1 2 3 4 5 6 7 8
Findings/Assessment Summary 8 7 6 5 4 3 2 1 RCT 1 2 3 4 5 6 7 8
_________________________ 8 7 6 5 4 3 2 1 Impacted 1 2 3 4 5 6 7 8
_________________________ LOWER RIGHT LOWER LEFT
_________________________. 8 7 6 5 4 3 2 1 With caries 1 2 3 4 5 6 7 8
Recommendations 8 7 6 5 4 3 2 1 Amalgam 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 Other resto mat 1 2 3 4 5 6 7 8
_________________________
8 7 6 5 4 3 2 1 Pontic 1 2 3 4 5 6 7 8
_________________________
8 7 6 5 4 3 2 1 Missing 1 2 3 4 5 6 7 8
_________________________. 8 7 6 5 4 3 2 1 RF 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 Unerrupted 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 For exo 1 2 3 4 5 6 7 8
Dentist: ___________________ 8 7 6 5 4 3 2 1 TF 1 2 3 4 5 6 7 8
Signature: __________________ 8 7 6 5 4 3 2 1 Abutment 1 2 3 4 5 6 7 8
License Number: _____________ 8 7 6 5 4 3 2 1 RCT 1 2 3 4 5 6 7 8
Date Examined: ______________ 8 7 6 5 4 3 2 1 Impacted 1 2 3 4 5 6 7 8

EVALUATED BY:
Name and signature of WPU Health Services Personnel: ___________________________________
Position / designation: _______________________________ Date Evaluated: _______________
WPU-QSF-HSD-05 Rev.03 (07.06.21)