HWC-004-13-03

OUR LADY OF FATIMA UNIVERSITY

HEALTH ANDWELLNESS CENTER
VALENZUELA CITY- QUEZON CITY- ANTIPOLO- PAMPANGA CAMPUS

Part I: PERSONAL PROFILE (Part I to V will be answered by the student)

Last Name:_______________________________First Name:_________________________________Middle Name:__________________________
Age:_____Gender:________Civil Status:_________Religion:_________Nationality:__________Date of Birth________Place of Birth_____________
City Address______________________________________________________Phone No. /Cellphone No:___________________________________
Provincial Address_________________________________________________Course:________________Student Number: ___________________
Mother’s Name:______________________________Age:______Occupation:___________________Office No./Cell No._______________________
Father’s Name:_______________________________Age:______Occupation:___________________Office No./Cell No._______________________
Person to Notify in case of Emergency:___________________________________________________Office No./Cell No.______________________
Hospital of Choice in case of Emergency: Fatima University Medical Center (FUMC) ______Other (please specify) ___________________________

Part II: PAST MEDICAL HISTORY (Part II to VI: Please check the corresponding boxes). Attending/Family Physician (if any):______________
Place a mark on “Yes” or “No” to indicate if you have had any of the following diseases:
Disease Yes No Disease Yes No Disease Yes No Disease Yes No
Mumps Heart Disease Bleeding Problem Bronchial Asthma
Measles Kidney Disease Behavioral Problem Skin Asthma
Chicken Pox Liver Problem/Hepatitis Infection Hearing Impairment Cancer
Dengue Fever Epilepsy/seizure/convulsion Speech Problem Diabetes
Typhoid Fever Fainting Visual Problem (wearing glasses?) Hypertension
Pneumonia Insomnias Ear Discharge Anemia
Primary Complex (PTB) Migraine Abdominal pain/ Peptic Ulcer Fracture/ scoliosis
Tonsillitis Vertigo Operation Surgery Parasitism
Dermatologic disease Congenital Defect Hospital Confinement Allergies
Psychological disease Hernia Other Please Specify:

FOR FEMALE: Menstrual History FOR MALE: Circumcision History

Age of Menarche: ____Cycle: Regular _____ Irregular______ Circumcision: Done: ____Not Done____
Napkin per day: ____Fully Soaked ___Minimally Soaked_____ When? __________
Duration: ____ Interval: ____Dysmenorrhea: Yes ____No____

Part III: PSYCHOSOCIAL HISTORY

No Yes If Yes:
Drinking How much? How often?
Smoking No. of Stick per day: Since When?
Drug Abuse Kind? Regular use? Yes: No:
Abuse: Physical Findings if any:
Verbal
Sexual

Part IV: Family History

Disease Yes No Relation Disease Yes No Relation
Cancer Mental Problem
Heart Problem Asthma
Hypertension Tendency Bleed
Diabetes Tuberculosis
Kidney Problem Rheumatism
Seizure Disorder Convulsion
Stroke Obesity
Liver Disease Skin Disease

Part V: Immunization/Medication
Vaccine/Booster Yes No Vaccine/Booster Yes No Vaccine/Booster Yes No Vaccine/Booster Yes No
BCG MMR Anti-Typhoid Fever Anti-Hepa A
DPT Anti-Measles Anti-Hepa B Hib
IPV/OPV Anti-Chickenpox Tetanus/Diphtheria Flu Vaccine
Pneumococcal Meningococcemia Other: (please specify)

Present Medication: Indication: Dosage:

1._______________ _______________ _______________
2._______________ _______________ _______________

I hereby certify that the above information is true and correct.

I authorized emergency medical treatment and/or transportation to a medical facility for any injury or illness deemed
urgently necessary by the University clinic staff and/or by the guidance counselor.
Conforme:
_____________________________________ _____________________________________
Signature of the student Parent/Guardian Signature over printed name
Date:_________________________________ Date:_________________________________
 HWC-004-13-03
OUR LADY OF FATIMA UNIVERSITY
HEALTH ANDWELLNESS CENTER
VALENZUELA CITY- QUEZON CITY- ANTIPOLO- PAMPANGA CAMPUS

Part VII: Physical Examination (To be accomplished by the clinic staff)

Height: Weight: BMI: BP Temp: PR/Min: RR/Min

Normal Abnormal Normal Abnormal

1. Skin ______ ______ 9. Lungs ______ ______
2. Head, Neck, Scalp ______ ______ 10. Heart ______ ______
3. Eyes ______ ______ 11. Abdomen ______ ______
4. Ears ______ ______ 12. Back ______ ______
5. Nose, Sinuses ______ ______ 13. Anus, Rectum ______ ______
6. Mouth, Throat ______ ______ 14. Genitals ______ ______
7. Neck, Thyroid ______ ______ 15. Reflexes ______ ______
8. Chest, Breast, Axilla ______ ______ 16. Extremities ______ ______
Recommendation:_________________________________________________________________________________________________________
Impression: ______________________________________________________________________________________________________________

LABORATORY AND ANCILLARY PROCEDURES

Procedure Result

FITNESS TO WORK CLASSIFICATION:

CLASS A - Physically fit for any work
CLASS B - Physically under-developed or with correctible defects, (error of refraction, dental caries, defective
hearing, and other similar defects) but otherwise fit to work.
CLASS C - Employable but owing to certain impairments or conditions, (heart disease, hypertension, anatomical
defects) requires special placement or limited duty in a specified or selected assignment requiring
follow-up treatment/periodic evaluation.
CLASS D - Unfit or unsafe for any type of employment (active PTB, advanced heart disease with threatened failure,
malignant hypertension, and other similar illnesses).

Remarks/Recommendations:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

______________________ ______________________________
Date examined School physician