Form No.

IFD-COP-REGT001-002
BOHOL ISLAND STATE UNIVERSITY Revision 00
Main Campus Related Process BISU-COP-REGT-001
C.P.G. North Avenue, Tagbilaran City, Bohol Effectivity Date:
ENROLLMENT FORM
(NEW STUDENTS)

SCHOOL YEAR SEMESTER DATE

ENROLMENT TYPE
☐ NEW STUDENT ☐ TRANSFEREE ☐ SHIFTEE ☐ CONTINUING ☐ RETURNING
BASIC INFORMATION
LAST NAME, FIRST NAME MIDDLE NAME
2" x 2"
Recent ID Picture
STUDENT ID COURSE MAJOR YR.

DATE OF BIRTH (MMM DD, YYYY) PLACE OF BIRTH

SEX CITIZENSHIP CIVIL STATUS RELIGION

CONTACT INFORMATION
MOBILE NO. PERMANENT ADDRESS

EMAIL ADDRESS PRESENT ADDRESS

EMERGENCY CONTACT PERSON

FATHER'S NAME MOTHER'S NAME (Not maiden name)

FATHER'S OCCUPATION MOTHER'S OCCUPATION

PARENT'S MOBILE NO. PARENT'S ADDRESS ZIP CODE (Optional)

GUARDIAN'S NAME (Optional) GUARDIAN'S ADDRESS

EDUCATIONAL BACKGROUND
ELEMENTARY SCHOOL ELEMENTARY SCHOOL ADDRESS SCHOOL YEAR

SENIOR HIGH SCHOOL SENIOR HIGH SCHOOL ADDRESS SCHOOL YEAR

OTHER COLLEGE / SCHOOL LAST ATTENDED (If any please specify.)

SCHOLARSHIP VERIFICATION (To be filled up by SAS Scholarship in-charge.)

SCHOLARSHIP FULL MERIT SIGNATURE OF SAS IN-CHARGE

☐ YES ☐ NO

SUBJECT CODE SUBJECT DESCRIPTION UNITS INSTRUCTOR

I certify that I am the data subject, and the information given above is correct to the best of my knowledge and belief. I hereby consent Bohol Island State University to
store
and process my information under the terms of Republic Act No. 10173 also known as the Data Privacy Act of 2012.

STUDENT SIGNATURE

CLINIC (For new students only.) CASHIER (For CAdS & 2nd courser students only.)

GUIDANCE (For new students only.) COLLEGE DEAN REGISTRAR

BOHOL ISLAND STATE UNIVERSITY | Office of the Registrar | RO Student Enrolment Form
 BOHOL ISLAND STATE UNIVERSITY
Main Campus
UNIVERSITY HEALTH SERVICES

Mission: A premier Science and Technology university for the formation of world class and virtuous human resource for sustainable
development in Bohol and the Country.

Vision: BISU is committed to provide quality higher education in the arts and sciences, as well as in the professional and technological fields;
undertake research and development and extension services for the sustainable development of Bohol and the country.

NAME: ______________________________ BIRTHDAY: _______________

Last name, First name, Middle initial Month/ day/ year

DATA SUBJECT CONSENT

In accordance with the provisions of the Data Privacy Act of 2012 and its corresponding
regulations, we implement appropriate security measures to safeguard the personal data we collect. We
assure you that your personal data will be collected, processed, and stored with the utmost care for the
purpose of health assessment, treatment, and/or research, adhering to ethical research guidelines to
enhance healthcare services. The Bohol Island State University Health Service maintains strict security
and confidentiality protocols when handling personal data.

By providing my authorization and consent, I acknowledge and agree to the aforementioned

purposes. I understand that this consent will remain valid until I choose to revoke it in writing.

CONSENT FOR ASSESSMENT

I hereby provide my voluntary consent for the healthcare professionals at Bohol Island State
University Health Service to perform a comprehensive physical examination and mental health
screening, review my laboratory tests, and administer any necessary treatment before admission
to the University.

________________________________
Name and Signature over printed name / Date signed
 BOHOL ISLAND STATE UNIVERSITY
Main Campus
UNIVERSITY HEALTH SERVICES

Mission: A premier Science and Technology university for the formation of world class and virtuous human resource for sustainable
development in Bohol and the Country.

Vision: BISU is committed to provide quality higher education in the arts and sciences, as well as in the professional and technological
fields; undertake research and development and extension services for the sustainable development of Bohol and the country.

In order to finalize your admission to Bohol Island State University (BISU), it is mandatory to
undergo a comprehensive medical history and physical examination. The completion of this rests solely,
and is the responsibility of the STUDENT and not of the physician. Kindly fill out this form legibly using
BLACK ink. Your submitted form will be kept confidential and will be included in your enrollment medical
records. Please ensure that your medical history and physical examination are completed and on file prior
to your registration.

You are REQUIRED to fill out this form if you are a/an:
1. Newly admitted undergraduate or post-graduate student of BISU 2x2 picture
2. Transfer student from another school or university
3. Cross-enrolling student from another campus in BISU
4. Returning student from Leave of Absence (LOA) or Absence
Without Leave (AWOL) for whatever reason

Name: ____________________________________________________
Last Name, First Name, Middle name

Civil Status: □ Single □ Married □ Widowed □ Legally separated

Date of Birth: _______________ Birthplace: __________________________________
Campus: _____________________________Course & Year: _____________________
□ Freshman □ Post-graduate □ Transferee
□ Cross-enrollee □ Returning from LOA/AWOL
Home address: ___________________________________Contact No: ___________
Street, Barangay/ City/Municipality/ Province

Address while in school: ____________________________Contact No: ___________

Name of Parent/Guardian: ___________________________
Landlord/Landlady: _________________________________
Address: _________________________________________Contact No: ___________

PERSONAL HISTORY
□ Allergies (please specify) ______________________ □ No known allergies
Are you taking medications regularly? □ Yes □ No If yes, please specify: ________________
Are you differently abled? □ Yes □ No If yes, please specify: ________________
Are you left handed? □ Yes □ No
 BOHOL ISLAND STATE UNIVERSITY
Main Campus
UNIVERSITY HEALTH SERVICES

Mission: A premier Science and Technology university for the formation of world class and virtuous human resource for sustainable
development in Bohol and the Country.

Vision: BISU is committed to provide quality higher education in the arts and sciences, as well as in the professional and technological
fields; undertake research and development and extension services for the sustainable development of Bohol and the country.

Have you ever had any of the following diseases or problems? Check the corresponding box.

Yes No Remarks
Headaches (frequent)
Dizziness (frequent)
Fainting/Loss of consciousness
Insomnia
Depressed mood (>2 weeks)
Eye/Visual problems
Hearing problems
Cough (>2 weeks)
Colds/ Nasal congestion
Fever (frequent/recurrent)
Frequent early morning sneezing
Nosebleed (frequent)
Sore throat (frequent)
Chest pain
Back pain
Easily gets tired
Difficulty breathing
Palpitations
Swelling of feet
Nausea (frequent)
Vomiting
Abdominal pain/discomfort
Loss of appetite
Weight loss/gain Specify:
Diarrhea/constipation Specify:
Joint pains
Muscle pain (frequent)
Frequent urination
Eczema/Skin problems
Fracture
Accident/Injuries
Hospitalization Reason:
Operation Specify:
Others Specify:

Give the appropriate AGE to which you had the following.

Age N/A Age N/A

Anemia/Blood Disorder Measles
Asthma Mental problem/disorder
Cancer Mumps
 BOHOL ISLAND STATE UNIVERSITY
Main Campus
UNIVERSITY HEALTH SERVICES

Mission: A premier Science and Technology university for the formation of world class and virtuous human resource for sustainable
development in Bohol and the Country.

Vision: BISU is committed to provide quality higher education in the arts and sciences, as well as in the professional and technological
fields; undertake research and development and extension services for the sustainable development of Bohol and the country.

Chickenpox Neurologic problem/disorder

Convulsions Pertussis (whooping cough)
Dengue Pleurisy
Diabetes Pneumonia
Diphtheria Poliomyelitis
Ear disease/defect Rheumatic fever
Eye disease/defect Skin disease
Gonorrhea Syphilis
Heart disease Thyroid disease
Hepatitis (indicate type) Tonsilitis
Hernia Tuberculosis/Primary complex
High blood pressure Typhoid
Influenza (indicate date) Ulcer (peptic)
Joint pains Ulcer (skin)
Kidney disease COVID-19
Malaria Other conditions: please list

IMMUNIZATION RECORD

Date given Date given

BCG Hepa A Dose 1
Hepa B Dose 1 Dose 2
Dose 2 COVID 19 vaccine brand:
Dose 3 Dose 1
Tetanus Toxoid Dose 2
Rabies Vaccine Booster 1
Flu Booster 2
Pneumococcal
• Write N/A if vaccine not given,

FOR FEMALE STUDENTS:

Menstruation: Age of onset: __________ Regularity: □ Regular □ Irregular
Duration: ______ days Flow: □ Light □ Moderate □ Heavy
Dysmenorrhea: □ Yes □ No Last menstrual period (month and year): _______
Have you had any trouble with your breasts, such as lumps, tumor, surgery? □ Yes □ No
If so, give details: ___________________________________
 BOHOL ISLAND STATE UNIVERSITY
Main Campus
UNIVERSITY HEALTH SERVICES

Mission: A premier Science and Technology university for the formation of world class and virtuous human resource for sustainable
development in Bohol and the Country.

Vision: BISU is committed to provide quality higher education in the arts and sciences, as well as in the professional and technological
fields; undertake research and development and extension services for the sustainable development of Bohol and the country.

FAMILY HISTORY
Mother: Living ______ (indicate age)
Diseases: _____________________ Maintenance medications: ___________
If deceased, _________ (age of death) Cause of death: ___________________
Father: Living ______ (indicate age)
Diseases: _____________________ Maintenance medications: __________
If deceased: __________(age of death) Cause of death: ___________________
If married:
Spouse: Living: ______ (indicate age) General health: □ Excellent □ Good □ Fair □ Poor
Diseases: ______________________ Maintenance medications: ___________
If deceased: __________(age of death) Cause of death: ___________________
Children: ________ (number of children)
Health problems: _________________________________________
Among your blood relatives, is there a history of any of the following?

Yes No Relation Yes No Relation

Cancer Diabetes
Heart disease Mental disorder
High blood pressure Asthma
Stroke Neurologic
problems/convulsions
Tuberculosis Bleeding disorders
Kidney Disease Digestive problems
Arthritis/Rheumatism Skin disease

I confirm that I have provided a truthful account of my history to the best of my knowledge. Furthermore,
I have made a complete disclosure of all medical conditions that could potentially impact my performance
as a student at the University.

______________________________________
Signature above printed name / Date signed
 BOHOL ISLAND STATE UNIVERSITY
Main Campus
UNIVERSITY HEALTH SERVICES

Mission: A premier Science and Technology university for the formation of world class and virtuous human resource for sustainable
development in Bohol and the Country.

Vision: BISU is committed to provide quality higher education in the arts and sciences, as well as in the professional and technological
fields; undertake research and development and extension services for the sustainable development of Bohol and the country.

Name: _________________________________________ Age: _______ Sex: ______ Civil Status: _______________

DO NOT WRITE BELOW THIS LINE. TO BE FILLED OUT BY PHYSICIAN.

Vital Signs:

PR: _____ bpm BP:______ mmHg RR: _____ cpm Temp: _____℃ 02 sat: _____ %

Anthropometric measurements:

Height: _______ cm Weight: ______ kg BMI: _______ [wt in kg/ (ht in m) 2] ________

General Health Appearance: □ Excellent □ Good □ Fair □ Poor

Visual Acuity: Without Glasses With Corrective Lenses Color Vision

Right: _____________ _____________ _____________

Left: ______________ _____________

• Check corresponding boxes

Organ/Systems Normal Abnormal If abnormal, describe findings

Skin
Head/Scalp
Eyes
Ears
Nose
Mouth/oropharynx
Neck
Heart
Lungs
Back/Spine
Abdomen
Extremities
Genito-urinary/Anorectal
Neurologic

Diagnostic/ Laboratory results:

□ Normal chest findings □ Stool exam within normal limits

□ CBC within normal limits □ Hepatitis B non-reactive

□ UA within normal limits □ Neuropsychiatric exam within normal limits

Activity:

□ Unlimited □ Unlimited with Observation □ Restricted and Corrective □ Reconstructive □ No activity

ASSESSMENT RECOMMENDATIONS

__________________________________ ____________________________________

__________________________________ ____________________________________

□ FIT TO ENROLL □ FIT FOR OJT or INTERNSHIP

Examined by: ___________________________

PRC License no: ________________________

Date examined: _________________________

 BOHOL ISLAND STATE UNIVERSITY 5. Proceed to the School of Medicine lobby with the
UNIVERSITY HEALTH SERVICES photocopy of your laboratory results, photocopy of
Mission: A premier Science and Technology university for the formation of world class and virtuous human
resource for sustainable development in Bohol and the Country.
COVID 19 vaccine card (if vaccinated), and filled up Pre-
Vision: BISU is committed to provide quality higher education in the arts and sciences, as well as in the
professional and technological fields; undertake research and development and extension services for the
sustainable development of Bohol and the country.
enrollment health form.

Patient’s Name: _________________________ Date:__________

Year & Course / Office: _________________________ 6. Have an RCY volunteer take your vital signs,
Campus: ___ Main ___ Balilihan ___ Bilar
___ Calape ___ Candijay ___ Clarin including height, weight and BMI.

Rx 7. Follow the arrows to the second floor to have your

LABORATORY REQUEST FOR:
Ishihara test for color blindness.
CHEST X-RAY
COMPLETE BLOOD COUNT
URINE ANALYSIS 8. Undergo physical examination from our doctors and be
STOOL EXAM declared fit for enrollment.
HEPATITIS B TEST - HBSAG
SNELLEN’S TEST
ISHIHARA TEST FOR COLOR BLINDNESS
Note:
NEUROPSYCHOLOGICAL TEST
DRUG TEST
1. Pregnant students MAY NOT submit a chest x-ray.
Pearl Dianne B. Lopez, MD
Medical Officer III Instead, submit a copy of your ultrasound result or pre-
Lic. No. 0152484
natal record.
(Please cut the Laboratory Request Form above this line)

Pre-enrollment clinic process. 2. Medical requirements are not free and are not included
1) Download and print the Pre-enrollment health form and in the free higher education, thus expenses will have to be
the laboratory request prescription form according to your shouldered by the enrollees.
course.
3. Validity of requirements are: 1 week for CBC,
2) Fill up the printed Pre-enrollment health form. urinalysis and stool exam and 3 months for chest
x-ray. Have your chest x-rays done first in case x-ray
3) Proceed to the nearest laboratory facility near you. The results may take awhile to be released.
clinic will accept results from private laboratory
institutions BUT WE HIGHLY ENCOURAGE THAT 4. Incomplete requirements will not be accepted.
YOU GET TESTED IN GOVERNMENT-OPERATED
LABORATORY TESTING CENTERS.

4) Comply with the following requirements depending on

your course and PHOTOCOPY your results.
 BISU-F- GDC 005
Rev. 00
BOHOL ISLAND STATE UNIVERSITY
Effectivity Date: 09-01-18
C.P.G. North Avenue, Tagbilaran City
Guidance Center INDIVIDUAL INVENTORY FORM

INDIVIDUAL INVENTORY FORM

Dear Student,
The purpose of this form is to gather essential information that will enable your Guidance Counselor to help
you in whatever way possible. Be assured that all information shall be kept with utmost confidentiality.

Date: ____________ A.Y. 20___- 20___

Student Number/I.D. Number: _______________________ Course: ______________________

______________________________________________________________________________________
(Family Name) (First Name) (Middle Name) (Nickname)
Age: ________ Gender: _______________________ Civil Status: ________________ ______________
Date of Birth: _______________________ Place of Birth: _________________________________
Religion: ____________________________ Nationality: ____________________________________
Mobile #: __________________________________ Tel. #: ___________________________________
Email Address: ______________________________________________________________________
City Address: __________________________________________________________________________________________________________
Home Address: ________________________________________________________________________________________________________

FATHER MOTHER
Name
Home Address
Contact Number
Date of Birth
Nationality
Educational
Attainment
Occupation
Place of Employment
Monthly Income

Parents
___ Living Together ___ Permanently Separated ___ Temporarily Separated
___ Father – OFW ___ Mother – OFW

Name of Brothers/Sisters Age School/Place of Work

Place + sign after name, if deceased.

Guardian (if not living with Parents): _________________________________________________________________________________________

Relationship with Guardian: __________________________________________ Contact #: ____________________________________________
Address: _________________________________________________________________________________________________________________________

Easiest Subjects: ________________________________________________________________________________________________________________

Difficult Subjects: _______________________________________________________________________________________________________________
 Inclusive Years Honors/Awards
Name & Address of School
of Attendance Received
Elementary
Secondary
Tertiary*
______________________
_
Graduate Studies*
______________________
_
*Please write the degree and major.

Name of Organization/s that You are a member of Position School Year

Interests: ________________________________________________________________________________________________________________________
Skills/Talents: ___________________________________________________________________________________________________________________
Hobbies: _________________________________________________________________________________________________________________________
Ambitions: _______________________________________________________________________________________________________________________
Present Concerns: ______________________________________________________________________________________________________________
Fears: ____________________________________________________________________________________________________________________________
Philosophy/Motto in Life: ______________________________________________________________________________________________________
Traits that You Possess:
Friendly ( ) Easily Troubled ( ) Happy-Go-Lucky ( )
Stubborn ( ) Confident ( ) Calm ( )
Relaxed ( ) Imaginative ( ) Practical ( )
Tense ( ) Suspicious ( ) Trusting ( )
Worrier ( ) Serious ( ) Shy ( )
Reserved ( ) Outgoing ( ) Dominant ( )
Self-assured ( ) Perfectionist ( ) Flexible ( )
Individualistic ( ) Group-Oriented ( ) Traditional ( )

Others (Please specify.): ________________________________________________________________________________

Disabilities/Impairments: ______________________________________________________________________________________________________
Chronic Illnesses: _______________________________________________________________________________________________________________
Medicines Regularly Taken: ____________________________________________________________________________________________________
Accidents Experienced/Effect: _________________________________________________________________________________________________
Operations Experienced/Effect: _______________________________________________________________________________________________

To whom would you like to share your concerns and problems with? Why?
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________

Would you like to see and talk to your guidance counselor?

____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________

____________________________________________
Signature over Printed Name
Guidance Form 5A

Republic of the Philippines

BOHOL ISLAND STATE UNIVERSITY-MAIN CAMPUS
Tagbilaran City, Bohol

Vision: A premier S & T university for the formation of world class and virtuous human resource for the sustainable development in Bohol and
the country.
Mission: Committed to provide quality and innovative education in strategic sectors for the development of Bohol and the country.

Name: ______________________________________________________ Course & Year: ________________ Date: _________________

Learning Style Inventory

To better understand how you prefer to learn and process information, place a check in the appropriate space
after each statement below, then use the scoring directions on the next page to evaluate your responses. Use what
you learn from your scores to better develop learning strategies that are best suited to your particular learning
style. This 24-item survey is not timed. Respond to each statement as honestly as you can.

Some-tim
Often Never
es
1. I can remember best about a subject by listening to a lecture that includes
information, explanations and discussions.
2. I prefer to see information written on a chalkboard and supplemented by
visual aids and assigned readings.
3. I like to write things down or to take notes for visual review.
4. I prefer to use posters, models, or actual practice and other activities in class.
5. I require explanations of diagrams, graphs, or visual directions.
6. I enjoy working with my hands or making things.
7. I am skillful with and enjoy developing and making graphs and charts.
8. I can tell if sounds match when presented with pairs of sounds.
9. I can remember best by writing things down.
10. I can easily understand and follow directions on a map.
11. I do best in academic subjects by listening to lectures and tapes.
12. I play with coins or keys in my pocket.
13. I learn to spell better by repeating words out loud than by writing the words
on paper.
14. I can understand a news article better by reading about it in a newspaper
than by listening to a report about it on the radio.
15. I chew gum, smoke or snack while studying.
16. I think the best way to remember something is to picture it in your head.
17. I learn the spelling of words by “finger spelling” them.
18. I would rather listen to a good lecture or speech than read about the same
material in a textbook.
19. I am good at working and solving jigsaw puzzles and mazes.
20. I grip objects in my hands during learning periods.
21. I prefer listening to the news on the radio rather than reading the paper.
22. I prefer obtaining information about an interesting subject by reading about
it.
23. I feel very comfortable touching others, hugging, handshaking, etc.
24. I follow oral directions better than written ones.
Guidance Form 5A

Scoring Procedures
Directions: Place the point value on the line next to the corresponding item below. Add the points in each
column to obtain the preference score under each heading.

OFTEN = 5 points SOMETIMES = 3 points SELDOM = 1 points

VISUAL AUDITORY TACTILE

NO. PTS. NO. PTS. NO. PTS.
2 1 4
3 5 6
7 8 9
10 11 12
14 13 15
16 18 17
19 21 20
22 24 23

VPS = APS = TPS =

VPS = Visual Preference APS = Audio Preference TPS = Tactile Preference

Source: www.sgibson.k12.in.us/gshs_new/.../Assignemt_1_Learning_Style_Inventroy.pdf