Republic of the Philippines

PARTIDO STATE UNIVERSITY

Camarines Sur

PSU-F-CLI-04

STUDENT HEALTH RECORD

Name: ___________________________________________________ Age: _______ Civil Status: _______

Surname First Name Middle
Address: ____________________________________________ Course/Year: __________ S/Y: __________
Father’s Name: _______________________________Mother’s Name: ____________________________
Occupation: __________________________________ Occupation: _______________________________
Office Address: _______________________________ Office Address: _____________________________
Tel. /CP No.: __________________________________ T el. /CP No.: _______________________________
Name of Guardian: _____________________________ Address: __________________________________
T el. /CP No.: ______________________________
_____________________________________________________________________________________________

FAMILY HISTORY: Please check in the space provided & indicate relationship among your blood relatives, if there
is any of the following illnesses.

Illnesses Yes No Relation Illnesses Yes No Relation

Skin Problems ___ ___ _______ Heart Disease ___ ___ _______
Asthma ___ ___ _______ Hypertension ___ ___ _______
Bleeding Tendency ___ ___ _______ HIV / AIDS ___ ___ _______
Cancer ___ ___ _______ Hepatitis ___ ___ _______
Convulsion ___ ___ _______ Kidney Problems ___ ___ _______
Diabetes ___ ___ _______ Mental Disorder ___ ___ _______
Eye Disorder ___ ___ _______ Rheumatism ___ ___ _______
Skin Problems ___ ___ _______ Heart Disease ___ ___ _______
Others (Specify) ___ ___ _______ Tuberculosis ___ ___ _______
_____________________________________________________________________________________________

PERSONAL HISTORY: Please check in the space provided if you had the following symptoms and illnesses.

I. Past Illnesses:

____________ Asthma ____________ Measles

____________ Anemia / Leukemia ____________ Mumps
____________ Chicken Pox ____________ Mental Disorder
____________ Diabetes ____________ Pneumonia
____________ Dengue ____________ Poliomyelitis
____________ Ear Problem ____________ Rheumatic Fever
____________ Eye Disorder ____________ Primary Complex
____________ Heart Disease ____________ Thyroid Disorder
____________ Hepatitis ____________ Typhoid Fever
____________ Kidney Disease ____________ Tuberculosis
____________ Skin Disorder / Allergies ____________ Others (Specify)

II. Present Illnesses / Present Symptoms

_______ Chest Pain _______ Headaches ______ Nausea / Vomiting

_______ Insomnia _______ Indigestion ______ Sore Throat
_______ Difficult Breathing _______ Joint Pains ______ Swollen Feet
_______ Dizziness _______ Weight Loss ______ Frequent Urination
_______ Palpitations _______ Convulsion ______ Others (Specify)

Effectivity Date: July 01, 2019 Rev. No. 02 Page 1 of 2

 Republic of the Philippines
PARTIDO STATE UNIVERSITY
Camarines Sur

PSU-F-CLI-04

III. Do you have a history of hospitalization for serious illnesses, operation or injury? Yes No
If yes, give details

IV. Are you taking any medicines regularly? Yes No

If yes, please write the name of drug/s details

V. Are you allergic to any food or medicine (penicillin, aspirin, etc.)? Yes No
If yes, please specify

VI. Immunization History

BCG Polio vaccine I, II, III, Booster Doses

Chickenpox DPT I, II, III, Booster Doses
Typhoid German measles
Measles Mumps
Hepatitis A Hepatitis B
Others (specify)

VII. In case of emergency, person to be notified aside from parent or guardian:

1. Tel/ CP#
2. Tel/ CP#
3. Tel/ CP#

VIII. Data Privacy: Choose and shade your choice from the choices below:

o I am giving my consent on sharing my personal information for the purpose of studies, surveys, research,
accreditation and ISO audit only

o I want to keep my information private

Student Signature Over Printed Name Date

Effectivity Date: July 01, 2019 Rev. No. 02 Page 2 of 2