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Medical Health Record 2 LONG

This document contains a health record form with sections to be filled out by a student/parent and a school physician. The student/parent section collects medical history, family history, and personal details of the student. The school physician section includes a psychosocial history, physical examination findings, fitness certification, impressions, and recommendations. The form allows collection of a student's health information to assist a school in identifying medical needs and ensuring student safety and wellness.

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ipanagclaire8
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48 views2 pages

Medical Health Record 2 LONG

This document contains a health record form with sections to be filled out by a student/parent and a school physician. The student/parent section collects medical history, family history, and personal details of the student. The school physician section includes a psychosocial history, physical examination findings, fitness certification, impressions, and recommendations. The form allows collection of a student's health information to assist a school in identifying medical needs and ensuring student safety and wellness.

Uploaded by

ipanagclaire8
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CARD-MRI DEVELOPMENT INSTITUTE INC.

HEALTH RECORD

PART 1 (to be filled up by Student / Parent)


SHS: Section: Adviser:
College: Course / Blk: Adviser:
Staff: Unit:
Name: Civil Status: Gender:

Address: Age:

Nationality: Birthday: Birthplace: Tel/Cel No.

Spouse Name if Married: Religion:

Contact No. Address: Occupation:

Mother/ Guardian’s Name: Address:

Contact No. Occupation:

Father’s Name: Address:

Contact No. Occupation:

Call in case of emergency : Name: Relation to Student:

Contact No. Address:

Hospital of choice for referral or admission:

Contact No(s):

A. MEDICAL HISTORY B.FAMILY HISTORY

ILLNESS NO YES DISEASE NO YES


Allergy Allergy
Anemia Cancer
Asthma Bleeding Problem
Behavior Problem / Hysterical Diabetes
Bleeding Problem Epilepsy
Chicken Pox Heart Problem
Collapse when having Menstrual Period Hypertension
Collapse when anxiety attack Kidney Disease
Convulsion Mental Problem
Diabetes Obesity
Dengue Stroke
Ear Problem Tuberculosis
Eating Disorder HAS THE STUDENT EXPERIENCED:
Eye Problem Hospitalization: NO YES Reason:
Epilepsy Surgery/ Operation: NO YES Reason:
Fainting On special medication: NO YES Reason:
Fracture C. FOR BOYS
Hearing Problem
Circumcision DONE: NOT DONE
Heart Problem (Heart attack, heart
failure, congenital heart condition, high
blood pressure) FOR GIRLS
Hyperventilation during Anxiety / Panic Age of menarche Last menstrual period
attack
Hyperventilation and Palpitation
Cycle: Regular (Days) Irregular (Days)
Hypertension
Indigestion Flow: Minimal Moderate Profuse
Insomnia
Intestinal Worm Having trouble before/during Menses? YES/NO
Kidney Disease State here:
Liver Disease
Lung Disease
Measles
Mental Problem
Mumps I hereby certify that the foregoing answers are true and complete,
Nervous Breakdown and to the best of my knowledge.
Pneumonia
Skin Problem
Speech Problem
Spine Disorder
Stroke
Tonsilitis
Tuberculosis
Typhoid Fever Student’s Parent/
Others Guardian’s signature over
Printed Name Student’s Signature / Date
Part 2 (to be filled up by the School Physician)
A. PSYCHOSOCIAL HISTORY
1. Do you have close friends? Yes ___ No ___ (Only 1? __ More than 1 __) Vaccine:
2. Do you drive? Yes ___ No ___ (Regularly? ___ No __Yes)
3. Do you drink alcohol bev.? Yes ___ No ___ (How often? _____________ How much? ________)
4. Do you smoke? Yes ___ No ___ (Sticks/Day? ____ Since when? ________________)
5. Have you taken illicit drugs? Yes ___ No ___ (Kind? ________________ Regular use? __No __Yes)
6. Experienced abuse? Yes ___ No ___
Physical Yes ___ No ___
Sexual Yes ___ No ___
Verbal Yes ___ No ___

PHYSICAL EXAMINATION

DATE:
Weight
Height
BP
Pulse
Skin
Head
Eyes
Vision
Ears
Hearing
Nose
Throat
Mouth
Gums
Neck
Chest
Lungs
Abdomen
Limbs
Neuro

Other significant findings:

Fitness certification: Fit for enrollment Not fit for enrollment Pending, Reason:

Impression/s: Recommendations:

The above findings are certified and are based on the physical examination, diagnostic results available, and the disclosure of the
patient’s pertinent medical history at the time and date of examinations.

________________________________ ___________________ ______________


School Physician’s signature over printed name License No. Date of Examination

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