Republic of the Philippines

BICOL UNIVERSITY
BICOL UNIVERSITY HEALTH SERVICES
Legazpi City STUDENT HEALTH RECORD
Contact Number 09164058966

Course: ___________________________
School Year: _______________________
Campus: __________________________
(Use BLUE permanent ink. DO NOT USE sign pen. Print on Legal size paper back-to back))

Name _________________________________________________________________________________ Age ______ Sex _________

(Last) (First) (Middle)
Date of Birth _________________ Civil Status: ________________ Nationality: __________________ Religion __________________
Permanent Home Address: ____________________________________________________ Student’s Contact No.________________
Father’s Name ________________________________________ Mother’s Name __________________________________________
Occupation __________________________________________ Occupation _____________________________________________
Office Address ________________________________________ Office Address ___________________________________________
Father’s Contact No. ___________________________________ Mother’s Contact No. _____________________________________

Guardian ____________________________________________
Guardian Address _____________________________________ Guardian Contact No. _____________________________________
________________________________________________________________________________________________________________________________________________________________________

Please check the box if one of the following is applicable to you

Family History: Personal Social History:
□ Cancer □ Diabetes Mellitus □ Eye disorder
□ Heart diseases □ Mental Illness □ Skin Problems □ Smoking(□ Cigars □ Vape)___sticks/day for___ year/s)
□ Hypertension □ Asthma □ Kidney Problem
□ Thyroid Disease □ Convulsions □ Gastrointestinal disease □ Drinking ( ____ beer per ___________) or
( ____ shots per __________)
□ Tuberculosis □ Bleeding Disorder □ Others _____________

PERSONAL HISTORY
Past Illness: Present Medical Condition: (If Any)
□ Primary Complex □ Asthma □ Rheumatic Fever □ Chest Pain □ Headaches □ Nausea/Vomiting
□ Chicken Pox □ Diabetes □ Mental Disorder □ Insomnia □ Indigestion □ Sore Throat
□ Kidney Disease □ Eye Disorder □ Skin Problems □ Joint Pains □ Swollen Feet □ Frequent Urination
□ Typhoid Fever □ Pneumonia □ Poliomyelitis □ Dizziness □ Weight Loss □ Difficulty of Breathing
□ Ear Problems □ Dengue □ Thyroid Disorder □ Abdominal Pain □ Palpitation □ Seizure / Convulsion
□ Heart Disease □ Measles □ Anemia □ Irregular Menses (Female)
□ Leukemia □ Hepatitis □ Mumps □ Others ___________________________________________
• Do you have history of hospitalization for serious illness, operation, fracture or injury? _______If yes, please give details:
___________________________________________________________________________________________________
• Are you taking any medicine regularly? ________ If yes, name of drug/s: _____________________________________
(Ex: Vitamins, Oral Contraceptive Pills)
• Are you allergic to any food or medicine? ________ If yes, specify: ___________________________________________
IMMUNIZATION HISTORY:
□ BCG □ Polio Vaccine I, II, III, Booster Dose □ Mumps □ Typhoid □ Hepatitis A
□ Chicken Pox □ DPT I, II, III, Booster Dose □ Measles □ German Measles □ Hepatitis B
□ Flu □ Pneumonia □ HPV □ COVID-19: _________________________
□ Others: _______________ ( Booster If Any: ):_________________
I hereby certify that the foregoing answers are true and complete, and to the best of my knowledge.

_________________________________________ _________________________________________ ___________________

Signature of Student Signature of Parent/Guardian over Printed Name Date Signed
DO NOT WRITE BELOW THIS LINE. TO BE ACCOMPLISHED BY THE MEDICAL PERSONNEL
VITAL SIGNS: ANTHROPOMETRICS: Please attach official reading and result of the following:
BP: _____/_____mmHg Height: ______meters CHEST X-RAY FINDINGS: ____________________________________
PR: __________/minute Weight: ______kgs. CBC Result: _________________Blood Type: ___________________
RR: __________/minute BMI: ______________ Urinalysis: _______________________________________________
Temp: ____________oC Hepatitis B Screening: ______________________________________
O2 Saturation: ______%

Doc. No. BU-F-UHS-05

Effectivity: March 24, 2023
Revision: 3 Page 1 of 2