PERSONAL HEALTH HISTORY

(ALL INFORMATION IS CONFIDENTIAL TO THE SCHOOL-BASED CLINIC)

Name: Jenny B. Mercado Student No. s2020100136 Age: 17 Date

Course / Level / Section: STEM 12-E Allied Health Science Birthday: September 02,
Sex: Female 2004
Address: # 211 Brgy. Mabini, Tanauan City. Batangas Religion: Catholic
Guardian: Yolanda B. Mercado Contact No. of Guardian: 09052437877
CHECK ALL BOXES THATAPPLY. 9. Have you had any previous operations?
1. Do you have the following conditions TODAY? No Yes Specify.
Colds(sipon) Yes No Skin Rashes Yes No 10. Do you smoke cigarettes? Yes No
Cough Yes No Pain in Urination Yes No If yes, how many cigarettes per day?
Fever Yes No Constipation (Hirap Dumumi)Yes No How old are you when you started smoking?
Throat Pain Yes No Hemorrhoids (Almuranas) Yes No 11. Do vou drink anv tvpe of alcohol?
Headache Yes No Mass (Bukol ) Yes No Yes No If so, what kinds?
Dizziness Yes No Others. 12. Check if anvone in the Familv had/has the If:
2. Have vou had anv of these Childhood Diseases? Asthma Seizures or epilepsy
Primary Complex (TB sa Bata) Yes No I don’t know Anemia Mental health problems
Chicken pox (Bulutong Tubig) Yes No I don’t know Liver disease Cancer Migraine
Measles(Tigdas) Yes No I don’t know headaches Kidney disease
Mumps (Beke) Yes No I don’t know Gallbladder disease Thyroid disease
Others.
Alcohol/drug use Diabetes
3. Immunization \Bakuna):
High blood pressure Heart disease/stroke
Complete Incomplete I don't know
Arthritis Others. None
4. Allergies: Medicine Pollen Food Pets I do not know my family history
Specify. None
5. Present Illnesses: FEMALES ONLY
Asthma Pulmonary Tuberculosis 1. LMP (Last Menstrual Period) Jan 08, 2018
Shortness of breath Chest pain and/or heart murmur (DATE of the FIRST day of your last menstruation?)
(when you p/ay sports or exercise) Skin problems 2. Menstrual cycle started at what age? 15 to 16
Frequent headaches Wear contacts/glasses 3. Menstruation is monthly? Yes No
or migraines Hearing problems 4. How many days do you bleed?
Others None 5. Do you experience problems or pain during
6. Medications vou are presentlv takina: menstrual periods? Yes No
Vitamins Herbal supplements Others 4. Did you miss school for cramps? Yes No
Specify. None
S. What medication have you used for cramps?
7. Have you ever been admitted / confined in the hospital?
No Yes What Sickness? None Does it help? Yes No
8. Have you had any accidents before? Yes No
Specify.
The above information is true and correct to the best of my knowledge

Name & Signature:

For Clinic use only

Remarkable PE Findings:
Present Medical History:

Physical Examination: COM MENTS:

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processing of the above personal and sensitive information in relation to school
medical services.
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