DAVAO MEDICAL SCHOOL FOUNDATION

Dr. A Gahol Avenue, Bajada, Davao City

SCHOOL CLINIC

PHYSICAL EXAMINATION REPORT

Date: 5-19-23
Name: Cosare Alessandra Maxinne Empas Age: 19 Sex: Female Status:
(Lastname) (Firstname) (Middle Initial)

Address: #11 Hyacinth st., Alpha Homes, Matina Aplaya, Davao City
Date of Birth: Nov. 5, 2003 Religion: Catholic Course: Dentistry
Contact #: 0961 939 8789
Person to Contact in Case of Emergency: Lorena Cosare Contact #: 0948 329 4050

I, Alessandra Maxinne Cosare, 19 , years old accept and understand that I am required
to undergo a physical examination and chest x-ray to determine my fitness and well-being as a student. I
fully understand that the results will be held as confidential medical records and will be used by the
school for my care and treatment. My health information cannot be released to third persons except with
my consent or unless the disclosure of the information is required by law. I also accept and understand
that the procedures are requirements for the next academic year enrollment. I acknowledge that my
medical records will be retained by the school for a period of 5 years from examination or health visit.

Alessandra Maxinne E. Cosare

Signature of Guardian Signature over Printed Name of Student

Risk Assessment Tool (for 10 to 18 years old and 364 days)

(to be filled up by a Doctor)

Home

Education

Eating

Activity

Drugs

Sexuality

Suicidality/Depression

Safety

Spirituality/ Strengths
avao City
I. PAST MEDICAL HISTORY

1. In the past, did you suffer any of the following? (Yes or No)
Asthma No Sexually Transmitted Disease No Cough Yes
Bronchitis No Skin Disease/ Allergy No Difficulty of Swallowing Yes
Cancer No Tuberculosis No Difficulty of Urination Yes
Chicken Pox Yes Ulcer No Headache Yes
Diabetes No Abdominal Pain Yes Hearing Problem No
Diarrhea Yes Allergic Rhinitis (frequent sneezing) No Impaired Sight No
Goiter No Back Pain No Fainting No
Hypertension No Bloody Stool Yes Seizures No
Pneumonia Yes Chest Pain No Spitting Blood No
Rheumatism No Constipation Yes Toothache No

2. Have you undergone any operation? (Yes or No). If YES, specify No

3. Have you been hospitalized? (Yes or No).
If YES, specify (Date & Diagnosis) Yes, Admitted for Pneumonia (4 years old)

II. FAMILY HISTORY

(Please check) Cancer Heart Disease
Hypertension Bronchial Asthma
Diabetes Skin Allergy
Rheumatoid Arthritis

III. SOCIAL HISTORY

Smoking No Sticks/day? 0 No. of years Smoking?
Alcoholic Drinking Yes How Often? occasionally
Exercising Yes How Often? 2x a week
Food Allergy No If YES, Please Specify
Drug Allergy No If YES, Please Specify

IV. VACCINATION HISTORY

Have you been Immunized or Vaccinated with (Yes or No)
Anti Hepatitis B No Chicken Pox Yes
Anti Hepatitis A No Flu Yes
Tetanus Toxoid Yes Pneumococcal Vaccine Yes
COVID-19 Yes

Covid-19 Vaccine Brand Date

1st Dose Pfizer June 2021
2nd Dose Pfizer July 2021
1st Booster Pfizer 02/10/22
2nd Booster Pfizer -

Other vaccinations received: (Please Specify)

V. Obstetric/ Gynecologic History

For Female Only: G P A
What Family Planning Method are you using?
Your (LMP) Last Menstrual Period Date:
Did you have a Pap smear in the past? (Yes or No)
PHYSICAL EXAMINATION (to be filled up by a Nurse/ Doctor)
Blood Type Extremities:
Blood Pressure Left Handed
Respiratory Rate Right Handed
Temperature Snellen:
Pulse Rate Right Vision
Height: Weight: Left Vision
BMI Corrective Lens

Laboratory Date: Non-Reactive

Results Abnormal Findings HbsAg Reactive
Date:

CBC Anti-hbs
Hgb:
Normal

Fecalisis Malarial Test

Normal Drug Test

Chest X-ray
Physical Findings Abnormal Findings
Normal
EENT
Urinalysis Normal

Normal Head and Neck

Normal
Breast Abdomen
Normal Normal

Skin
Lungs
Normal
Normal

Heart
Normal

Neurologic
Normal

REMARKS:

Physically Fit
For Clearance

RECOMMENDATION:
Nurse Signature Examining Physician