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School: LASICAM-PERRAL NATIONAL HIGH SCHOOL

(CHECK COLUMN IF APPLICABLE)

PAST HEALTH HISTORY PRESENT HEALTH STATUS


Surgical Others
BP (Use
Designa previous Hyper Diabetes Cardiovasc Allergy Tuber Cough Dizzi Chest/ Joint Blurring of Wering Painful Poor/ fain Vaginal
NAME Age Smoking Asthma ular Back Urina loss Goiter Convulsi Dis Opera (specify, add
tion records) tension mellitus Diseases (specify) culosis (duration) ness Pain pains Vision eyeglasses tion hearing ting on charge tion colum if
(Specify) needed)

ALFIE L. CAGAMPANG 32 SST-II 120/80

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