PAMANTASAN NG LUNGSOD NG MARIKINA

1x1
ID picture
taken within
the last 6
months

Brazil St., Greenheights Subdivision, Concepcion I, Marikina City

UNIVERSITY CLINIC
CONTACT NO. 9757064

MEDICAL RECORD FOR STUDENTS

PRE ENROLLMENT MEDICAL
REQUIREMENTS:

CHEST XRAY within 6 months ( 1 photocopy , 1 original)

Complete Blood Count ( 1 photocopy , 1 original)
Urinalysis ( 1 photocopy , 1 original)
Physical Examination
(1) LONG WHITE FOLDER
[1] 1 x 1 ID Picture

MEDICAL RECORD

MUST BE COMPLETED.
PLEASE DONT LEAVE ANY QUESTION UNANSWERED.

PLEASE WRITE IN PRINT.

NAME:

Last Name

First Name

Middle Name

ADDRESS:
No.

Street

Barangay

City

Course, Yr. & Section:

OCCUPATION: (if any)

CONTACT NUMBER :

DATE OF BIRTH :

GENDER:

AGE:

Month/Day/Year

Male

CIVIL STATUS:

Female

PRESENT ILLNESSES :

RELIGION:

MEDICATIONS TAKEN :

PAST MEDICAL HISTORY :

[
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[
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[
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[
]
[
]
[
]

Allergy
Asthma (Bronchial/Skin)
Eye problems
ENT disorders (Ears,
Nose, Throat)
Frequent headaches
Head or neck injury

[
]
[
]
[
]
[
]
[
]
[
]

[
]
[
]
[
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[
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[
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[
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Blood disorders
Hypertension
Heart disease
Endocrine disorder
(Diabetes, Goiter)
Lung disorder (PTB ,
COPD)
Cancer or tumor

Kidney or bladder problems

Genitourinary (STD, UTI)
Viral Illnesses (Chicken pox,
Measles)
Gastrointestinal disorder (Hepatitis,
Ulcer)
Neurologic Disorder (Seizure,
Mental disorder
Others : ___________________________

PREVIOUS OPERATION/S :

FAMILY HISTORY :
[
]
[
]
[
]

Allergy
Asthma
Cancer

[
]
[
]
[
]

PERSONAL/SOCIAL HISTORY :
Hypertension
Heart disease
Thyroid
disease

[
]
[
]
[
]

Diabetes
Mellitus

[
]

Kidney disease

[ ]

Others:
_________

EMERGENCY CONTACT PERSON:

(Do not put your OWN number. Significant persons only -parents, siblings, guardian or if married wife, husband, or
child of legal age)
Name:
Contact number(s):
Relationship:

Smoking _____ sticks _____ year

Drinking ___ beers per ______,
___ shots per ______

I certify that I have reviewed the information supplied by

me, and that it is true and complete to the best of my
knowledge.
SIGNATURE OVER PRINTED NAME
DATE:

DO NOT FILL BELOW THIS LINE. (FOR MEDICAL EXAMINER ONLY)

OB/GYNE HISTORY:
LMP __________________

PMP ______________

G ____ P ____ ( ____ , ____ , ____ , ____ )

Duration ________

Delivered by

Interval: ____ Regular ____ Irregular

____ NSD ____ CS

Complication/s : __________________________

VITAL
SIGNS : RESULTS :
LABORATORY

VISUAL ACUITY

Temperature
LABORATORY PROCEDURES

DATE

Chest
Xray
Pulse Rate
Respiratory
Complete
Blood Count (CBC)
Rate
Urinalysis
Blood Pressure
1st

PHYSICAL
Fecalysis
EXAMINATION

2nd

Ab
N

3rd

Wt

kg

Right
RESULTS

Ht

cm

Left

BMI

Remarks

[ ] Underweight
[ ] Normal

[
]
[
]

Uncorrected
Corrected

[ ] Overweight
[ ] Obese

General:
Blood
Chemistry
Skin:
ECG
Head
Eyes:
Serology
Ears/Nose/Throat:
Others
Neck: : __________________________
Chest:
CLASSIFICATION:
Lungs:
PHYSICALLY FIT
[ ]
Breasts:
[ ]
Physically fit but with minor ailment/s
Heart:
[ ]
Physically unfit but may be fit once with clearance or after treatment
Abdomen:
[ ]
Physically unfit
Genital:
Rectal:

DIAGNOSIS/IMPRESSIONS:

[ ] waived/refused
_________________________
Name and Signature of
Patient

Back:
Extremities:
Neurological:
Dental:

RECOMMENDATIONS:

_______________________________________
SIGNATURE OVER PRINTED NAME OF
PHYSICIAN
DATE ACCOMPLISHED:
____________________