HEALTH INFORMATION SHEET FOR STUDENT

Do not leave any item unanswered. Print, accomplish, sign, scan, and send this Health Information Sheet to
medical@pup.edu.ph

PART I. STUDENT INFORMATION

Name: DOWELL D. ARCANGEL

Date: SEPTEMBER 03, 2020
Address: 117 GEN. ALJENADRINO ST. BRGY. BAGONG SILANGAN, QUEZON CITY
School Year: 2020-2021
Age: 18 Sex: MALE Civil Status: SINGLE Course / College: BA IN BROADCASTING
Blood Type: N/A
Parent's Name / Guardian: ROBERT F. ARCANGEL
Landline: N/A Cellphone: 09166325883

PART II. MEDICAL HISTORY 1. Do you need medical attention or has known medical illness? ⬜
No ⬜ Yes (Please check the following that apply and give more information as needed) ⬜ Asthma ⬜
Fainting ⬜ Vision Problems ⬜ Hearing Problems ⬜ Diabetes ⬜ Heart Condition ⬜ Kidney Disease ⬜
Hearing Problems ⬜ Seizure Disorder ⬜ Hyperventilation ⬜ Hemophilia ⬜ Muscle Weakness/Paralysis ⬜
Migraine ⬜ Hypertension ⬜ Others (Pls. Indicate):

2.Previous Hospitalization: ⬜ No ⬜ Yes Year:

Operation/Surgery: ⬜ No ⬜ Yes Year:

3. Additional Information for Students with Medical Conditions: As a Parent/Guardian, I

would like to declare that my child/ward had history of allergies to the following: Food:
Medicines:

PART III. FAMILY HISTORY ⬜ Diabetes ⬜ PTB ⬜ Hypertension ⬜ Cancer ⬜ Others

(Pls. Indicate):

PART IV. PERSONAL HISTORY Cigarette

Smoking: ⬜ Yes ⬜ No Alcohol Drinking: ⬜
Yes ⬜ No Do you feel stressed: ⬜ Yes ⬜ No

I hereby state to the best of my knowledge, my answers to the above questions are
complete and correct.

By affixing my signature (Parent/Guardian), I am agreeing to the PUP Data Privacy Policy and
giving my consent in the collection and processing of the student's name above his/her Personal
Information in accordance thereto and be given medical and dental care by the PUP
physician/Dentist.

Signature of Parent/Guardian Signature of Student Date

Due to Community Quarantine, please be informed that Physical Examination for enrollment
and submission of chest x-ray is temporarily deferred until further notice.
REPUBLIC OF THE PHILIPPINES ) CITY OF MANILA ) S.S. FORM 1