Republic of the Philippines

Student ID # __________________
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur (c/o clinic staff)
CSPC-F-MeD-01
HEALTH ASSESSMENT FORM
DATA SUBJECT ACKNOWLEDGEMENT AND INFORMED CONSENT:
“I hereby allow CSPC and its authorized personnel to collect and process the relevant data provided by me and consent to
the confidential performance of legitimate clinic functions such as health assessment, examination, diagnosis, treatment,
health evaluation, certification, emergency transfer, referral, reporting, validation, data security, and compliance to
legal requirements. I also have been made aware of my data privacy rights to be informed, to object, to access, to
rectification, to erasure / blocking, and right to damages and impact of such rights towards my medical & dental care.”

__________________________________
Signature Over Printed Name
*For Data Privacy concerns, you may contact the CSPC Data Protection Officer at (054) 288-4421 (loc. 117).
**for Clinic concerns you may call (054) 288-4421 (loc. 117) or text 0915-931-6811 (Globe), or 0951-932-3739 (Smart).

Name:_________________________________Age:______Sex:_______Birth Date:__________________
Permanent Address:____________________________________________________________________
Present Address:_________________________________________ Cel No./Tel. No. ________________
Course/Position:_________________________ Civil Status:____________Blood Type (if known): _____
Father’s Name:__________________________ Mother’s Name:_________________________
Emergency Contact Person:________________________ Cel.No./Tel. No. ____________
Relation of the person stated above:_______________________________________________________

HEALTH EXAMINATION
M/D/Y M/D/Y M/D/Y M/D/Y M/D/Y
Date of Examination
1. Height (cm)
2. Weight (kg.)
3. Blood Pressure
4. Temperature
5. Pulse Rate
6. Respiratory System
Chest X-Ray (Optional)
7. Circulatory System
8. Digestive System
9. Genito – Urinary
System
10. Locomotion System
11. Nervous System
12. Skin
13. Eyes
14. Vision:
With Glasses:
Without Glasses:
15. Ears:
Left:
Right:
16. Nose
17. Throat
18. Teeth And Gums
19. Remarks

20. Recommendations

Examining / Certifying
Physician
(Name And Signature)
License Number
Note: To Be Accomplished By Any Physician/Doctor

Effectivity Date: January 2019 Rev.3 Page 1 of 2

 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
CSPC-F-MeD-01
(Note: This portion is to be accomplished by the student/employee. Please give clinical history you wish to
voluntarily disclose especially cases that need assistance from the Clinic. Rest assured that your information will be
handled with utmost confidentiality. Example: Disability, Maintenance Medicines, Chronic/Long-term Illness, etc.)

Part II – Health History:

Instruction: Please check (/) the blank if your answer is YES, and leave the blank (__) if otherwise on any
of the following conditions:

1. Family History (Common to Family Members):

__________ Asthma __________ Diabetes Mellitus
__________ High Blood Pressure/ Hypertension __________ Cancer
__________ TB / Pulmonary Tuberculosis __________ Eye Problem
__________ Mental Illness (Nearsighted, Farsighted, etc.)

2. Personal History:

Deformities / Disabilities Operations underwent, if any (please specify):

___________ Congenital (at birth) ___________________, year:___________
___________ Acquired ___________________, year:___________

Eyes, Ears, Nose and Throat Respiratory and Cardiac

___________ Eye Problem (Nearsighted, Farsighted, etc.)
___________ Ear Problem (Hearing loss, Vertigo, etc.)
___________ Ear Infection (Otitis Media, etc.)
___________ Sinusitis
___________ Allergic Rhinitis
___________ Mouth Sores
___________ Sore Throat / Pharyngitis
___________ Tonsillitis
___________ Dental Problem (Carries, Abscess, etc.)
___________ Gum Problem
Gastrointestinal / Digestion
___________ Appetite disorder / loss
___________ Abdominal pains / Indigestion
___________ Nausea / Vomiting disorder
___________ Hyperacidity / Peptic Ulcer
___________ Hepatitis / Jaundice
___________ Gallbladder Disease
___________ Diarrhea
___________ Dysentery (Amoebiasis, Cholera, etc.)
___________ Typhoid Fever
___________ Parasitism (Worms, etc.)
___________ Constipation
___________ Hemorrhoids
Others
___________ Allergies (Food, Medicine, Skin)
___________ Arthritis
___________ Dengue Fever / Chikungunya
___________ Dysmenorrhea
___________ Kidney Disease
___________ Malaria
___________ Rheumatic Fever
___________ Skin Infections (ring worm, scabies, etc.)
___________ Urinary Tract Infection (UTI)
___________ Venereal Disease / STD / STI
___________ Chicken Pox
___________ Measles
___________ Mumps
___________ Rubella / German Measles
___________ Others (please specify):
_______________________________________
Medications presently taking, if any:
_______________________________________
_______________________________________
_______________________________________
_______________________________________
___________ Asthma
___________ Pleurisy
___________ Pneumonia
___________ Bronchitis
___________ Pertussis / Diphtheria
___________ Pulmonary Tuberculosis
___________ Anemia (low iron / low count)
___________ Low Blood Pressure
___________ Hypertension / High Blood
___________ Heart Disease / Disorder
___________ Blood or Bleeding Disorders
Mental or Emotional
___________ Headache / Migraine
___________ Fainting Spell
___________ Stammering
___________ Anxiety Disorder / Palpitation
___________ Insomnia
___________ Bedwetting
___________ Epilepsy/Convulsion/Seizure
___________ Depression / Mood Disorder
___________ Nervous Breakdown
If you answered ( / ) any of the Mental / Emotional
problems above, have you consulted anyone for
the said problem(s)?
___________ YES ___________ NO
If YES, to whom?
___________ Guidance Councilor
___________ Psychologist
___________ Psychiatrist / Neurologist
___________ Others (please specify):
____________________
Lifestyle Risks:
___________ Smoking
___________ Drink alcoholic beverages
___________ Often eat fatty/oily/fried foods
___________ Often eat salty foods (junk/fast food)
___________ Often eat sweets / drink soft drinks
___________ Avoid/dislike/skip drinking water
___________ Stay up late at night / Sleep difficulty
___________ Skip meals at times
___________ Regular prolonged gadget use
___________ Often feel stressed/unhappy/discontent
___________ Don’t get regular exercise/walking

Effectivity Date: January 2019 Rev.3 Page 2 of 2