Republic of the Philippines

J.H. CERILLES STATE COLLEGE

Mati, San Miguel, Zamboanga del Sur
clinic@jhcsc.edu.ph

JHCSC Health Examination Record

Data Privacy Notice

The J.H. Cerilles State College (JHCSC) respects your right to privacy and is committed to protect the confidentiality of your personal information and
thus, has adapted the necessary measures to secure it. JHCSC is bound to comply with the Data Privacy Act of 2021 (RA 10173), its implementing Rules
and Regulations and relevant issuance o National Privacy Commission.

By Filling out this form, you are consenting to our collection of your information in accordance with this privacy notice.

I consent ________________________ _________________

Signature Date

Name: ______________________________________________________________________ Age: ________ Course: _____________________

Date of Birth: ____________________ Place of Birth: ______________________________ Civil Status:

__________

Permanent Address: ________________________________________________________________________

Name of Father/Mother: _______________________________________________Contact No: _______________

Name of Guardian (if applicable): __________________________________________ Contact No: _______________

Address: _______________________________________________________________________________

Medical Examination:
Height & Weight Weight: Height: Pulse Rate : Heart Rate :
Body Temperature
SpO2
Blood Pressure Systolic: Systolic: Systolic: Remarks/Treatment
Diastolic: Diastolic: Diastolic:

Family History: (Please put an “X” if yes or no and indicate relationship if yes)
Among your blood relatives, is there history of any of the following?
Ye No Relationship Ye No Relationship
s s
Cancer Diabetes
Heart Disease Mental Disorder
Hypertension Asthma
Stroke Convulsion
Tuberculosis Bleeding Tendencies
Kidney Problem Gastrointestinal Disease
Eye Disorder Skin Problem

Personal History: (Please put an “X” if you had the following symptoms or illness)

PAST ILLNESSES (Mga Naging Sakit)

Primary Complex Asthma Rheumatic Fever Chicken Pox
Kidney Disease Skin Problem Diabetes Eye Disorder
Pneumonia Dengue Measles Poliomyelitis
Ear Problem Mumps Thyroid Disorder Heart Disease
Mental Disorder Typhoid Fever Hepatitis Anemia/Leukemia

PRESENT ILLNESSES
Present Symptoms (Mga sintomas na mararamdaman)
Chest Pain Headaches Nausea/Vomiting Insomnia
Indigestion Sore Throat (Frequent) Difficult Breathing Joint Pains
Swollen Feet Dizziness Weight Loss Frequent Urination

 Do you have history of hospitalization for serious illness, operation, fracture or injury? ___ YES ____ NONE
 Are you taking any medicine regularly? ____ YES ____ NO. If yes, name of drug/s ____________________________________
_______________________________________________________________________________________________________.
 Are you allergic to any food or medicine? (ex. Penicillin, Aspirin, shrimp, chichen, etc) _____ YES _____ NO
If yes, specify ____________________________________________________________________________________________ .

Noted by:

JOANNE HAPPY C. HADJIRUL, RN

DM
School Nurse
HEALTH HISTORY COMMENTS: Include referrals and reports

Date Comments Signature & Title Date Comments Signature & Title

TREATMENT RECORD

Medication
Date Symptoms/Complaints First Aid Treatment/ Administered Name & Signature of
Non-Pharmacologic (Drug Dose, Clinic Nurse
Management Frequency)