J&T CLINIC

HEALTH
We Care for your Health HISTORY FORM
Please fill out the entire questionnaire. It will provide critical information about your health to
your healthcare staff. All responses to this form are strictly confidential and will be added to
your medical record.

Name (Last, First, M.I): O. C. T. A G E : 71 years old M F

D A T E O F B I R T H & P L A C E : SEPTEMBER 1, 1950; PACO, MANILA P H O N E N O . : 0920282808
A D D R E S S : MANILA CITY Single Divorced
MARITAL STATUS:
O C C U P A T I O N : HOUSEWIFE Married Widowed
RACE, ETHNICITY, & ORIGIN: Asian White American Indian Others:
REASON/S FOR SEEKING IMMEDIATE HELP: (e.g. chest pain for 2 hours)
DIALYSIS TREATMENT

Please circle any symptoms you are CURRENTLY experiencing or symptoms you have frequently
experienced in the past

Other Symptoms:
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All inquiries about the trip will be responded to immediately between the hours of 9AM to 6PM
 PAST HEALTH HISTORY
Please indicate if YOU have a history of the following and write N/A if the detail is unknown

CHILDHOOD ILLNESS: Measles Mumps Rubella Chickenpox Pertussis None

IMMUNIZATIONS AND DATE: Tetanus Pneumonia Hepatitis A 2021
MMR (measles/mumps/rubella) Chickenpox Hepatitis B 2021
Influenza Meningococcal None
A L L E R G I E S : Name: ALLEGRY IN PENCILLIN Reaction you had: ITCHINESS IN THE BODY
I have NO
allergies
ACCIDENTS OR INJURIES:
N/A FAINT (EYE PROBLEM) HOLY ROSARY HOSPITAL

SURGERIES:
N/A CAESAREAN (C-SECTION) CHINESE GENERAL HOSPITAL
N/A GOITER SURGERY CHINESE GENERAL HOSPITAL
2021 ACCESS SURGERY IN ARM (F0R HEMODIALYSIS ACCESS) PGH

CURRENT MEDICATIONS
List your prescribed medications and over-the-counter drugs such as vitamins, pills, inhalers etc.

Drug MULTIVITAMINS & IRON Dose/Frequency UNKNOWN DOSAGE / ONCE A DAY

Drug FEBUXOSTAT Dose/Frequency 40 mg / ONCE A DAY
Drug SEVELAMER Dose/Frequency 800 mg / ONCE A DAY
Drug AMLODIPINE Dose/Frequency 5 mg / ONCE A DAY
Drug TRIMETAZADINE Dose/Frequency 35 mg / ONCE A DAY
Drug LEVOTHYROXINE Dose/Frequency 50 mg / ONE AND HALF A DAY
Drug ATORVASTATIN Dose/Frequency 20 mg / ONCE A DAY
Drug PARACETAMOL & VITAMIN B COMPLEX Dose/Frequency 1 TABLET EVERY 12 HOURS WHEN IN PAIN
Drug INSUGET N Dose/Frequency 30-35 cc unit / ONCE EVERY MORNING
Drug ERYTHROPOIETIN Dose/Frequency 400 cc unit sq / ONCE A WEEK
List of additional drugs on back of questionnaires
I take NO medications, vitamins, herbals, or any other over-the-counter drugs.

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 FAMILY HISTORY
Please indicate if YOUR FAMILY has a history of the following: (ONLY include
parents, grandparents, siblings, and children)

I am adopted and do not know biological family

history
Family History Unknown Migraines
Alcohol Abuse Osteoporosis
Anemia Other Cancer
Anesthetic Complication Rectal Cancer
Arthritis Seizures/Convulsions
Asthma Severe Allergy
Bladder Problems Stroke/CVA of the
Bleeding Disease Brain
Breast Cancer Thyroid Problems
Colon Cancer NONE of the Above
Depression
Diabetes
Heart Disease Mother, Grandmother, or Sister
High Blood Pressure developed heart disease before the
High Cholesterol age of 65
Kidney Disease
Leukemia Father, Grandfather, or Brother
Lung/Respiratory Disease developed heart disease before the
age of 55

PSYCHOSOCIAL HISTORY

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FAMILY GENOGRAM
Physical and/or mental abuse has also become a major public health issue in this
country. This often takes the form of verbally threatening behavior or actual
physical or sexual abuse. Would you like to discuss this issue with your
provider?............................................................. YES NO

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 OTHER INFORMATION

PATIENT'S SIGNATURE: DATE: FEBRUARY 25, 2022

REVIEWED BY: JULIE ANN C. TOLENTINO DATE: FEBRUARY 25, 2022

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