Annex D

Central Philippine University

Jaro, Iloilo City

MEDICAL CLINIC
Medical History Form

Name: _______________________________________
Address: _____________________________________
Birthdate: __________________
Course and Level: ________________
Sex: ______
Civil Status: ________________
Parent /Guardian (or spouse): ____________________________ Contact number: __________

MEDICAL HISTORY
A. Allergies/ Reactions to Medications/Foods or Vaccinations?
Yes No If yes, please specify ________
B. Present illnesses: (Please check any that apply to your health)
Bronchial Asthma
Diabetes
Heart Defect/ Disease
Hypertension
Allergies
Mental Health Conditions
Epilepsy/ Seizure Disorder
Bleeding/ Clotting Disorder
Hepatitis

C. Current Medications (Please list current medication/maintenance meds if there are

any)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

D. Immunization:
VACCINE DATE RECEIVED
Dose 1 Dose 2 Booster Booster#2 Booster#3
COVID-19
Influenza (Flu)
Pneumonia
Hepatitis B
Others: (Please list
immunization
received)

PAST MEDICAL HISTORY

A. Hospitalizations and Dates:_______________________________________________
_____________________________________________________________________
Annex D

B. Operation and Dates: ___________________________________________________

_____________________________________________________________________

C. Serious Injuries and Dates: ______________________________________________

_____________________________________________________________________

FAMILY HISTORY
Please check any family history of the following: (indicate who has/had the
conditions)
Alcoholism/ Drug Abuse Heart disease or stroke
Psychiatric Disorder Thyroid Disease
High Blood pressure Bleeding/ Clotting problem
Asthma/ Hay fever/ Eczema Inherited/ Genetic disease

PERSONAL HISTORY

Do you smoke? Yes No

Do you drink intoxicating drinks? Yes No
Have you taken illegal drugs? Yes No

Emergency Contact Information

In case of emergency, who may we contact for you?

Name: _____________________________________________________
Cellphone number: ___________________________________________
Home phone number: _________________________________________
Workplace phone number: ___________________________________________
Address: ____________________________________________________
This person’s relation to you: ___________________________________