UMak-MDO-QF2 [rev4Feb2022]

UNIVERSITY OF MAKATI ID picture taken within

J.P. Rizal Extension West Rembo, Makati City the last 6 months
Medical and Dental Office 3.5 cm. X 4.5 cm
(passport size)
Medical and Dental Record Computer generated
or photocopied picture
is not acceptable
Date: __________________

Department: ____________

Name: ______________________________________________________________ Age: Date of Birth: _________________ _x000D_

Surname (Apelyido) First Name (Pangalan) Middle Name (Gitnang Pangalan) (Edad) (Araw ng kapanganakan)

Address: ___________________________________________________________________________________________________
(Lot Blk No.) (Street) (Barangay) (Municipality/ City)

Gender/Kasarian: Male Female Civil Status: Single Married Widow Others: ______________

Person to be Notified in case of emergency: ______________________________________________ Relationship: _________________

(Pangalan ng taong tatawagan kung may nangyari) (Kaugnayan sa Pasyente)

Address of Person to Notify: ____________________________________________________________________________________

(Tirahan ng taong tatawagan kung may nangyari)
Contact Number of Guardian: _________________________________________________________
(Numero ng taong tatawagan kung may nangyari)

MEDICAL HISTORY

Have you had any of the following diseases?

(Please Check the box/es)
Blood Type:______________ Covid Vax Status:_____________

Allergy (food/Meds) Epilepsy (Pangingisay) Kidney Disease Bronchial Asthma (Hika) Arthritis
Mumps (Beke) Typhoid Fever(Tipus) Hypertension Heart Disease Pneumonia
Measles (Tigdas) Malaria Diabetes Mellitus Dengue Fever Tuberculosis
Chicken Pox (Bulutong) Hepa A ( ) Hepa B ( ) Liver Disease ( ) Surgical Operations: ________________
Do not write below this line, to be filled up by Medical Personnel only

DENTAL ASSESSMENT/ EXAMINATION

LEGEND:
C = Carries
TX = For Extraction
RCT = Root Canal Treatment
Am = Amalgam
TF = Temporary Filling
CF = Composite Filling
P = Pontic
PJC = (Porcelain/Plastic) Jacket Crown

Remarks:

University Dentist Signature

MEDICAL ASSESSSMENT/ EXAMINATION

Laboratories Submitted
Chest Xray: Height: _________ Weight: _________
CBC:
Urinalysis: BMI: ______________
Fecalysis:
Neuro-Psych: V/A: OD ( R ) _______ OS ( L ) _______ w/C. L. ( )
Drug Test:
Others: BP: ___________________
Remarks:

University Physician Signature

Legend: Blank = No findings

Medical and Dental Record

DATE CHIEF COMPLAINS/ DIAGNOSIS TREATMENT/ REMARKS
 Medical and Dental Record
DATE CHIEF COMPLAINS/ DIAGNOSIS TREATMENT/ REMARKS