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Student Health Record PDF
Student Health Record PDF
Student Health Record PDF
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
Signature: __________________________
OR No.: __________________
Date Issued: _______________
Course: __________________
I. PERSONAL INFORMATION
Age: 18 years old Sex: [/ ] Male [ ] Female Civil Status: [ /] Single [ ] Married Blood Type: AB Positive
Date of Birth: November 23, 2002_____________________ Religion: Roman Catholic____________________
Birth Place: Puerto Princesa City, Palawan____ ______ Contact Number: 09300110185_________________
Permanent Address: Purok Centro, Bgy Tagburos, PPC
Address while in school: Santa Monica, Rafols Road, Puerto Princesa, Philippines
Name of Guardian / Spouse: Anna Chellie Crujido Contact Number: 09483768368
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: _________
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 ___________