MEDICAL RECORD

REGISTRATION DATA Date: mm/dd/yyyy

Name: Age: Gender: -

Birth Date: - Marital Status: - Number of Children:
Permanent
Address:
Contact No: Email Address:
Language
Spoken:
Occupation: Religion: -

VITAL SIGNS/ANTHROPOMETRICS

Temperature: ____________ Weight: ____________

Pulse Rate: ____________ Height: ____________
Respiratory Rate: ____________ BMI: ____________
Blood Pressure: ____________ Waist line/Hip line: ____________
W : H Ratio:
____________

MEDICAL HISTORY

Check (/) if you have ever been told by a physician that you have any of the following: *note the year of diagnosis

___ Stroke ___ Diabetes ___ Constipation

___ High blood pressure ___ Osteoarthritis ___ Cancer (Type)
___ High cholesterol ___ Liver disease ___ Other condition (Please specify)
___ High Triglycerides ___ Overweight
______________________________

Any history of trauma/accident/surgery (please specify):____________________________________________________

Any allergy to food/medicine/herbs (please specify):_______________________________________________________
Family history of heart disease, diabetes, hypertension:____________________________________________________
(Please provide a copy of medical report, investigations or blood works available)

LIFESTYLE BACKGROUND

PHYSICAL ACTIVITY – beyond daily occupation How would you rate your
___ None physical activity level?
___ Walked continuously, for at least 10 minutes, to get from a place to place (incidental only) ___ Very Active
___ Low intensity, sit-ups, stretching, fishing ___ Active
___ Moderate intensity, brisk walking, weight training, housework ___ Moderately Active
___ Vigorous activity, jogging, soccer, netball ___ Not Very Active
___ Not at all active
BREATHING – smoking history Rest and Stress
___ Non-smoker ___ 6 hours or less sleep/night
___ Ex-smoker ___ Sleep restlessly
___ Smoker ___ Suffer insomnia
___ Live with a smoker ___ hrs/week of work

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 Please fill in the number of servings you consume weekly (Pls. don’t leave blank)
May write None, 1-2x/week,3-5x/week, daily, more than once/day
___ Meat of shellfish ___ Fried foods ___ Honey/Syrups/Jelly
___ Chicken/Turkey ___ Salty snacks ___ Crackers/Cookies/Biscuits
___ Meat ___ Salad dressings ___ Fruits
___ Fish ___ Margarine ___ Vegetables
___ Whole milk or 2% ___ Gravies ___ Beans
___ Cheese ___ Soy meat/Gluten ___ Root Crops
___ Butter or cream ___ Plant-based milk ___ Whole wheat bread
___ Sour cream or mayonnaise ___ Water ___ Brown/Unpolished rice
___ Ice cream/Ice milk ___ Alcohol ___ Raw vegetable salads
___ Yogurt ___ Coffee/Tea/Chocolates ___ Pure Vegetable & Fruit blends
___ Liver/Organs meats ___ Soft drinks/Bottle juices ___ White rice/Maiz
___ Sausage/Hotdogs ___ Candy or sugar
___ Eggs ___ Sugary desserts

RECOMMENDATIONS:

DR. ELMER T. DE PERALTA

Physician | Philippine College of Lifestyle
Medicine

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