Republic of the Philippines

GOVERNOR MARIANO E. VILLAFUERTE COMMUNITY COLLEGE – LIBMANAN

Potot, Libmanan Camarines Sur
gmvcc.lib16@gmail.com

STUDENT HEALTH PROFILE

INFORMATION

Name: ________________________________________________________

Student ID Number: ___________________

Course and Year/Section: _________________________________________

Gender: ________ Date of Birth: _____________ Place of Birth: ___________________ Age: _________

Civil Status: __________________ Religion: _____________________ Mobile: _____________________

Home Address: ________________________________________________________________________

Father’s Name: _____________________________________________ Mobile: ____________________

Mother’ s Name: ____________________________________________ Mobile: ___________________

With whom does the student live? ___ Father ___ Mother ___ Both ___ Spouse ___Guardian

Guardian’s Name: ____________________________________________ Relation: __________________

Spouse Name: _______________________________________________ No. of Children: ____________

PAST MEDICAL HISTORY

Please check Y (yes) and N (no) for each condition.

Y N Y N Y N Y N
Allergies * Bronchitis Seizures Low Blood Pressure
Chills Joint Problems Back Pain Fever
Sinusitis Hemorrhoids Ear Infections Kidney Stones
Paralysis Dizziness Heart Disease * Excessive Fatigue
Anemia Chest Pain Tremors Chronic Swelling
Diabetes * Cancer * Vomiting Shortness of breath
Thyroid Convulsions Epilepsy Sexually Transmitted Disease *
Anxiety Meningitis Chronic Cough Urinary Tract Infections
Eczema Depression Chronic Colds Tuberculosis *
Arthritis Constipation Pneumonia Diarrhea
Nausea Fainting Malaria Hernia
Insomnia Nervous panic Appendectomy Heartburn
Asthma Head Injury High Blood Pressure Ulcers *
Hepatitis * Sickle Cell

Other health condition: _________________________________________________________________

Specify ( * ) :__________________________________________________________________________

PAST SURGICAL HISTORY (If Applicable)

Operation: ____________________________________________________ Date: __________________

PERSONAL / SOCIAL HISTORY

Smoking: ___Yes ___No ___Quit Year Started: _______ No. of pack (Months) _______________

Alcohol: ___Yes ___No ___Quit Year Started: _______ No. of bottles (day/month) __________

Illicit Drugs: ___Yes ___No ___Quit Year Started: _______ Type of Drugs: ____________________

GYNECOLOGIC/UROLOGIC HISTORY (if applicable)

FEMALE

Age at Menarche: ______________________

Last Menstrual Period: ______________________________

Menstrual Pattern (Cycle/Duration): _____________________________

Onset of sexual intercourse: ____________________________________

Pregnancy History: (GPFPA)___________________________________________________________

Gynecologic complaints and infection history: ____________________________________________

MALE

Age of Circumcision: __________________________

Urologic complaints and infection history: _______________________________________________

Person with disability: Yes or No_________________________________________ ID no. ___________

(Please mention or specify the condition/disability)

COVID VACCINE HISTORY

1st Dose: Date given: _________________ Vaccine Name: ____________________

2nd Dose: Date given: _________________ Vaccine Name: ____________________

Booster: Date given: _________________ Vaccine Name: ____________________

Health Facility Name: ___________________________________________________________________

AVAILABLE MEDICAL DOCUMENTS

Medical Certificate: _____________________________________________________________________

Medical Laboratories: ___________________________________________________________________

_______________________ ______________
Student Signature Date

AQUILINO C. DEBORDE, BSN-RN, LPT

School Nurse
 Republic of the Philippines
GOVERNOR MARIANO E. VILLAFUERTE COMMUNITY COLLEGE – LIBMANAN
Potot, Libmanan Camarines Sur
gmvcc.lib16@gmail.com

HEALTH RECORD

NAME: _______________________________________________________
DATE COMPLAINTS PHYSICAL EXAM MANAGEMENT
DATE COMPLAINTS PHYSICAL EXAM MANAGEMENT
Republic of the Philippines
GOVERNOR MARIANO E. VILLAFUERTE COMMUNITY COLLEGE – LIBMANAN
Potot, Libmanan Camarines Sur
gmvcc.lib16@gmail.com