HEALTH PROFILE OF TEACHING & NON-TEACHING PERSONNEL

Date: April 12, 2019

Name: AMOR F. CABATAN Date of Birth: 09/05/1990 Age:29 Gender: M

School/District/Division: Porac Integrated School Civil Status: S
Position/Designation: _________________________________________ Years in Service: _________

Family History: (pls. check) Y N Specify Relationship

Hypertension [ ] [ ] ____________________________________________
Cardiovascular Disease [ ] [ ] ____________________________________________
Diabetes Mellitus [ ] [ ] ____________________________________________
Kidney Disease [ ] [ ] ____________________________________________
Cancer [ ] [ ] ____________________________________________
Asthma [ ] [ ] ____________________________________________
Allergy [ ] [ ] ____________________________________________
Other Remarks: _____________________________________________________________________________________

Past Medication History: (check) Y N Y N

Hypertension [ ] [ ] Tuberculosis [ ] [ ]
Asthma [ ] [ ] Surgical Operation (pls. specify) [ ] [ ]
Diabetes Mellitus [ ] [ ] Yellowish Discoloration of Skin/Sclera [ ] [ ]
Cardiovascular Disease [ ] [ ] Last Hospitalization (reason) [ ] [
]
Allergy (pls. specify) [ ] [ ] Others (pls. specify) [ ]
[ ]

Last Taken Date Result Date Result

CXR/Sputum Result _______ _______ Drug Testing _______ _________ Others: Specify ______
ECG _______ _______ Neuropsychiatric exam _______ _________
Urinalysis _______ _______ Blood Typing _______ _________

Social History:
Smoking Y ______ N _____ Age Started: _______ Stick/packs per day: _____ Pack per Year: _______
Alcohol Y ______ N _____ How Often: _______ Food Preference: ____________________

OB Gyn History (pls. encircle) (Female Teachers)

Menarche: ____________ Cycle: ____________ Duration: _____________
Parity F P A L
Papsmear done Y N if Yes, when: _____________
Self Breast Examination done Y N
Mass Noted: Y N Specify where: ______________

For Male personnel: Digital Rectal examination done: Y N Date Examined: _________________________
Result: ________________________________

Present Health Status (pls. check) Y N Y N

Cough 2 weeks 1 month longer Lumps [ ] [ ]
Dizziness [ ] [ ] Painful Urination [ ] [ ]
Dyspnea [ ] [ ] Poor/Loss of Hearing [ ] [ ]
Chest/Back pain [ ] [ ] Syncope/Fainting [ ] [ ]
Easy Fatigability [ ] [ ] Convulsions [ ] [ ]
Joint/Extremity pains [ ] [ ] Malaria [ ]
[ ]
Blurring of Vision [ ] [ ] Goiter [ ] [ ]
Wearing Eyeglasses [ ] [ ] Anemia [ ] [ ]
Vaginal Discharge/Bleeding [ ] [ ] Others (pls. specify) __________________________

Interviewed by: ______________________________

Date: ________________________________________
CONSULTATION AND TREATMENT RECORD
Treatment /
Date Chief Compliant Findings
Recommendation