AHS-M-006

ATENEO DE MANILA UNIVERSITY

ATENEO HIGH SCHOOL HEALTH SERVICES

1 x 1 Photo

STUDENTS HEALTH INFORMATION SY _________

Please answer this form as accurate as possible. All the information contained within will be kept confidential

STUDENT INFORMATION
Name: _________________________________________________________________________Sex: ____ Age: _____ Date of Birth: ____/____/____
Year & Sec.: ___________ ID Number: _______________________
Cell phone: ___________________________________
Home Address: _________________________________________________________________ Home Phone: __________________________________
_____________________________________________________________________________________________________________________________
Name of Parent/ Guardian: ______________________________________________________ Home phone: __________________________________
Email Address: ______________________________________ Work phone: ______________ Cellphone: ____________________________________
Person to contact in case of emergency: __________________________________________ Cellphone: ____________________________________
Personal Physician: ___________________________________ Clinic phone: _____________ Office phone: __________________________________
MEDICAL HISTORY (To be completed by student or parents. Explain YES answer in the space provided below. Encircle questions you dont know answers to.)
YES NO
YES
1. Has a doctor ever denied or restricted your participation
19.Has a doctor ever told you that you have: (Check all that apply)
in sports or any physical activity for any reason?
High Blood Pressure
Heart Murmur
2. Have you had medical illness or injury since your last
High Cholesterol
Heart Infection
medical check-up or sports physical examination?
20.Has a doctor ever ordered a test for your heart (i.e. ECG
3. Do you have an ongoing medical condition (i.e., diabetes,
or echocardiogram)?
asthma or sickle cell anemia, etc..)?
21.Have you had a severe viral infection (i.e. myocarditis or
4. Have you ever been hospitalized for 1 or more days?
mononucleosis) within the last month?
5. Are you currently taking any prescription or over-the-counter
22. Has a doctor told you that you have asthma?
medication or using an inhaler?
23.Do you cough, wheeze or have difficulty of breathing
6. Do you have any allergies to pollen, latex, medicines, food,
during or after exercise?
24. Have you ever had a head injury or concussion?
insects, etc? If yes, please specify allergy below.
25.Have you ever been knocked out, became unconscious or
7. Any past surgical operation, accidents or non-sports
lost your memory?
related injuries?
26. Have you ever had seizure?
27. Do you have frequent or severe headaches?
8. Have you ever musculoskeletal injury like sprain,
28.Have you ever had numbness or tingling sensation in your
muscle or ligament tear, tendonitis, fractured bones or
face, arms, hands, legs or feet?
Dislocated joints? If yes, please put
below.
29.Have you ever been unable to move your arms or legs
9. Have you had a bone or joint injury that required x-rays, MRI, CT scan,
after being hit or after falling?
surgery, injections, rehabilitation, physical therapy session, use of brace,
30.When exercising in the heat, do you have severe muscle
cast or crutches? If yes, please encircle affected area below.
cramps or become ill?
31.Any known deformities (i.e. scoliosis, heart problem,
Head
Chest
Elbow
Hand
Thigh
Ankle
one kidney, blindness in one eye, one testicle, etc.)?
Neck
Shoulder
Forearm
Finger
Knee
Foot
32.Do you have groin pain or painful bulge or hernia in
Upper arm
Back
Wrist
Hip
Shin/calf
Toe
the groin area?
33.Do you use any protective/corrective equipment or medical
YES NO
devices that are not usually used for your sport or position
10. Does anyone in your family have a heart problem?
(i.e. knee brace, special neck roll, foot orthosis, shunt, teeth
11. Has anyone in your family die of heart problem or
retainers or hearing aid)?
sudden death before the age of 50?
34.
Have you had any problems with your eyes or vision?
12. Any serious family illness (i.e. diabetes, bleeding
31. Do you wear glasses, contact lenses or protective eyewear?
disorder, etc)?
36. Do you want a weight more or less than you do now?
13Any family history of cancer? Note the kind
37. Do you limit or carefully control what you eat or
of cancer below.
go on a kind of diet?
14.Have you ever had a rash or hives develop during or
38. Do you need to lose weight regularly to meet weight
after exercise?
requirement or your sport?
15.Have you ever passed out or been dizzy during or
39.
Do
you have any concerns that you would like to discuss
after exercise?
with a doctor?
16.Have you ever experienced/ felt discomfort, pain or
40. Check which immunization were given and the member of
pressure in your chest during exercise?
dose (s) received. Attach original/Xerox copy of immunization
17.Do you get tired more quickly than your friends do during
if available:
exercise?
Tetanus: ______ MMR: ________ Hepatitis B: _________
18.Does your heart race faster than normal or skip beats
Tdap: _______ Chicken: ________ Flu: _______________
(irregular beats) during exercise?
Explain YES answers here: (Attach additional sheets as needed.)
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
We certify that our answers to the above questions are complete and correct to the best of our knowledge.
_________________________________

Students Signature

______________________________________

Parent/Guardians Signature

___________________

Date

NO

Additional questions on more sensitive issues.

YES
NO
_________________________________________________________________________________________________________________________________________

Do you feel safe?

Do you ever feel sad, hopeless, depressed, or anxious?

Have you ever tried cigarette smoking, even one or two puffs? Do you currently smoke?

Do you take alcoholic drinks or use prohibited drugs (i.e. marijuana, cocaine, etc.)?

Have you ever taken steroids or used any other performance supplement?

Have you ever taken any supplements or vitamins to help you gain or lose weight or improve
your performance?
Explain YES answers here: (Attach additional sheets as needed)
_______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________

PHYSICAL EXAMINATION (To be completed by physician)

Students Name: ___________________________________________________________________
Height: _______________ Weight: ____________
Pulse rate: __________
RR: __________
Vision: Right 20/______ Left: 20/_______
Corrected: YES NO
Pupils:
Equal

BP: ___________
Unequal

Temp. ___________

NORMAL
ABNORMAL FINDINGS
1. General Appearance
______________
__________________________________________
2. Head
______________
__________________________________________
3. EENT
______________
__________________________________________
4. Lungs
______________
__________________________________________
5. Heart *
______________
__________________________________________
6. Abdomen
______________
__________________________________________
7. Genitourinary *
______________
__________________________________________
8. Skin
______________
__________________________________________
9. Lymph Nodes
______________
__________________________________________
10. Peripheral pulses
______________
__________________________________________
11. Neurologic Exam *
______________
__________________________________________
12. Musculoskeletal *
______________
__________________________________________
a. Neck
______________
__________________________________________
b. Back
______________
__________________________________________
c. Shoulder/Arm
______________
__________________________________________
d. Elbow/Forearm
______________
__________________________________________
e. Wrist/Hand
______________
__________________________________________
f. Hip/Thigh
______________
__________________________________________
g. Knee
______________
__________________________________________
h. Shin/Calf
______________
__________________________________________
i. Ankle/Leg
______________
__________________________________________
j. Foot
______________
__________________________________________
* Consider doing additional test for abnormal findings on history or physical exam (e.g., ECG, echocardiogram for
Abnormal cardiac findings, GU exam, cognitive evaluation / baseline neuropsychiatric testing or x-rays).

ASSESSMENT OF EXAMINING PHYSICIAN

I certify that the above examination was done with the following conclusion(s):
Cleared without limitations.
Cleared with precautions.
Cleared after completing evaluation/rehabilitation for _____________________________________________________________.
not cleared for _________________________________________ Reason: _____________________________________________
Recommendations: ____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Physicians Name and Signature: ______________________________________________ Date: ________________________

License Number: ___________________________
Cellphone: ____________________
Address: __________________________________________________________________ Clinic Phone: __________________
Modified from American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports
Medicine, and American Osteopathic Academy of Sports Medicine. 2010.
REVISED 2014

ATENEO DE MANILA HIGH SCHOOL

DENTAL HEALTH SERVICES

AHS-D-001
DENTAL EXAMINATION RECORD

Name of Student _____________________________________________ Year & Section __________ Date ____________

Surname
First Name
M.I
DENTAL HEALTH STATUS:

55

54

53

52

51

61

62

63

64

65

85

84

83

82

81

71

72

73

74

75

18

17

16

15

14

13

12

11

21

22

23

24

25

26

27

28

48

47

46

45

44

43

42

41

31

32

33

34

35

36

37

38

INITIAL SOFT TISSUE EXAM

ORAL HEALTH CONDITION

Date of Examination
Age last birthday
Presence of Debris
Inflammation of Gingiva
Presence of Calculus
Under Orthodontic Treatment

Y
Y
Y
Y

N
N
N
N

Y
Y
Y
Y

N
N
N
N

Dentofacial Anomaly, Neoplasm, Others, specify:

_______________________________________
__________________________________________
__________________________________________

Lips

Floor of Mouth

Palate

Tongue

Neck & Nodes

INITIAL PERIODONTAL EXAM

GINGIVAL INFLAMATION:
SOFT PLAQUE BUILDUP:
HARD CALC BUILDUP:
STAINS:
HOME CARE EFFECTIVENESS:
PERIODONTAL CONDITION:
PERIODONTAL DIAGNOSIS:
PERIODONTITIS:

Slight
Slight
Light
Light
Good
Good
Normal
Early

Moderate
Moderate
Moderate
Moderate
Fair
Fair
Gingivitis
Moderate

Severe
Heavy

Heavy

Heavy

Poor

Poor

Advanced

MUCOGINGIVAL DEFECTS:

TOOTH COUNT
Number of Teeth Present
Number of Caries Free Teeth
Number of Decayed Teeth
Number of Missing Teeth
Number of Filled Teeth
Total df &DMF Teeth

CLINICAL DATA
OCCLUSION:

Class 1

T.M.J. EXAM:

Pain

Class II

Class III

Popping

Deviation

Tooth Wear

DENTAL/ORAL EXAMINATION REVEALED THE FOLLOWING CONDITIONS AND RECOMMENDATIONS.

___________ Caries Free
___________ Poor Oral Hygiene (Materia Alba, Calculus, Stain)
___________ Indicated for Restoration/Filling
___________ Indicated for Extraction
___________ Gingival inflammation
___________ Needs Oral Prophylaxis

__________Needs Prosthesis (Denture)

__________For Endodontic Treatment
__________For Orthodontic Consultation
__________For Pits and Fissures Sealant Application
__________Others
__________No Dental Treatment Needed at Present

TO: THE EXAMINING DENTIST

Please accomplish the treatment needed and provide other dental history of the patient. Kindly sign and send back this form for inspection to the Ateneo de Manila
High School Dental Health Services.

Dental Treatment Given: ______________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
_______________________________________

Dentist Signature over Printed Name

License no.___________

Consent to Treatment
I hereby grant permission to the staff, physicians, and dentist of the Ateneo de Manila High School
Health Services to render my son any medical and/or dental treatment that they deem necessary as part of
first aid treatment especially during but not limited to emergency cases. I understand that the Ateneo de
Manila High School Health Services will make all possible effort to inform me in the event of such
treatment in an emergency.
By signing below, I attest that the information contained herein is correct to the best of my
knowledge and that I have read the CONSENT TO TREATMENT provision above, fully understand their
terms, and sign below freely and voluntarily without any inducement. I further acknowledge that I am the
parent or legal guardian of the student.

Parent / Legal Guardian Name (PRINT)

Parent / Legal Guardian SIGNATURE

Date: MM / DD / YYYY

Students Signature Over Printed Name