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Address:___PUROK1________________BANGAG_______________SOLANA____________CAGAYAN___
Street Brgy. City or Town Province
Previous hospitalizations:
Hospital: ___________________________________________________________________________________
Date: _______________________________________ Disease: _______________________________
Duration: ____________________________________ Attending Physician: _____________________
Remarks: ___________________________________________________________________________________
Have you had any surgeries before? Yes No
If so, please specify the details: ________________________________________________________________________
Drug History:
Have you experience any kind of communicable disease in the past? Yes No
If so, please specify: ________________________________________
Major injuries: ________________________________ Food and drug allergies: ________________________
WORK HISTORY:
Do you work full time? Yes No Student
How many hours per week? _____________________________
Describe your work/school:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Have you had any injuries or health problems in relation to your current occupation? If so, describe:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Are other workers similarly affected? Yes No
Is your work/school environment generally clean and safe? Yes No
If not, describe: _____________________________________________________________________________________
__________________________________________________________________________________________________
HOME EXPOSURE:
YES NO
Do you use pesticides at your home?
Do you live near an industrial plant, commercial business, dump site, or nonresidential property?
Have you ever changed your residence because of a health problem?
Does your drinking water come from city water supply?
Grocery store
Water well
Others, specify: ____________
Does your food come from somewhere other than a grocery store?
If yes, please specify: __________________________________
Is anyone else in your home environment having similar symptoms to yours?
If yes, please describe: _________________________________________
Do you experience any anxiety, depression, stress this past days? Yes No
If yes, state the factors that triggers this feeling: ___________________________________________________________
__________________________________________________________________________________________________
What methods or ways do you use to overcome or relieve this problem?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Is it effective? Yes No
What is your role in your family?
__________________________________________________________________________________________________
Does your family or friends help you whenever you have a problem? Yes No
Do you experience any violence within your family? Yes No