Republic of the Philippines Surigao Del Sur State University Bistig Campus Revision No. Barangay Maharka,Bishy Cty, Surigao del Sur 8311 Website: sdssu.edu ph HEALTH SERVICES DIVISION PERSONAL HEALTH STATE DECLARATION FORM Name: Date of Birth: ‘Surname. First Name ‘Middle Name Home Address: Status: Contact Person in case of emergency: Name: Contact No. ‘The patient/student must respond to all details of the health declaration with the help of his/her parent and/or a physician. Check the answer "Yes" or "No" in the body of the questionnaire. And affix your signature at the end of the form as required. [GENERAL QUESTIONS: Yes | No 1. Have you ever been hospitalized in a hospital/medical institute/clinie? When? Reason? [2. Have you ever had an operation or have been advised to have an operation? What kind? When? Reason? [3. Have you ever been injured? Do you have any disability? (Pls. elaborate) [4, Have you undergone routine tests? (Were the tests normal?) Pls. submit results if available. Blood tests? Urine tests? EKG? 5. Have you had imaging tests? Such as various types of X-rays? Pls. submit results available, Chest x-ray? Pls. submit results. (Should be taken within the last 6 months) Intestinal? (Ifany) Kidneys?(if any) Bones? (ifany) ‘Computerized Tomography (CT scan? State the reason, date and result (ifany) MRP? (Ifany) [6. Do you have any current liness or disease and have you received and/or are receiving treatment or medication? State what kind of sickness? What medication are you taking? (Dosage and duration of treatment.)7. FOR WOMEN ONLY - Do you suffer from any women's disease, such as! Yes |_NO Menstrual irregularity? Dysmenorrhea? Unusually heavy menstruation? Endometriosis? Fiboids (Myoma)?, Cysts (Ovarian)? Hemorrhages? Breast messes? (Uterus or Ovarian problems? (Other Gynecological Disorders? [&. FOR WOMEN ONLY - have you ever been advised to have a ‘Mammogram? Biopsy? (Operation of the breasts? Ultrasound of the pelvis? (Other gynecological examinations? [S. Do you smoke? IFYES, how many sticks a day? IFYES, since when did you start? [10, Do you drink alcohol, beer, or wine? [QUESTIONS ON ILLNESSES - HAVE YOU SUFFERED FROM OR ARE YOU NOW SUFFERING FROM: ‘ves [NO 14. Cardiovascular (Heart & Blood vessels) A. Heart disease 'B. Chest pains C Shortness breath D. Palpitations E. Angina pectoris F. Arrythmia G. Congenital Heart Defect or Disease (Pls state what kind) H. Hypertension 1. Leg pain while walking [12. Nervous System - Do you have the following: A, Dizziness. B. Headaches. C. Loss of consciousness D. Convulsions/Seizures (Epilepsy) E. Memory disorders F. Tremors G. Balance disorders Stroke |. Mental exhaustion 1. Vertigo 113. Mental Disorders - Do you have the following: ‘A, Mental disease B. Depression C. Schizophrenia D. Anxiety disorder E. Suicide attempt[14. Respiratory Tract - Did you ever had or have the following in the past or at present: YES [_NO ‘A. Asthma: B. Bronchitis C. Pheumonia D. Tuberculosis (T8) E. Hemoptysis (Coughing out of blood) F, Recurrent respiratory tract infection G. Persistent cough H. Difficulty in breathing 15. Digestive Tract & Liver - Do you have the following. ‘A. Ulcer (Gastric or Peptic) B. Heartburn . Intestinal problems - hookworm, ascariasis 1D, Hemorthoids & anal problems E Liver disease F. Hepatitis A G. Hepatitis 8 H. Jaundice I. Gallbladder stone 1 Pancreatitis K. Vomiting 116. Kidney & Urinary Tract, ‘A Kidney stones. 8 Nephritis C.Urinary tract defects D. Blood or protein in the urine E. Renal cysts F. Recurrent UTI 27. Endocrine (Metabolic disorders) ‘A. Diabetes Mellitus | or Il B. Disorder of the thyroid C.Endemic/toxic goiter D. Thyroid tumor E. Pituitary gland tumor F. High blood cholesterol & trigivcerides 18. Skin & Genital tract A. Herpes B. Psoriasis Eczema D. Tinea erusis E. Atopic Dermatitis, F. Contact dermatitis 39. Malignant disease AIDS B. Cancer [Pls Specify) 20. Joints & Bones A Arthritis B. Gout Back & Neck pain D. Joint pains[2a. Eyes (Please state your present condition) A Cataract 8. Glaucoma C. Strabismus (Squint) D. Colorblindness E, Visual disorders (Near or Far sighted) 22, Ear, Nose & Throat ‘A. Recurrent throat infection - Tonsiltis 8. Ear inflammation/infections (Otitis Media, Ear discharges) . Sinusitis (Acute or Chronic) D. Hearing disorders (Deafness) E. Allergic Rhinitis (23. Hemia - of the abdominal wall, groin, surgical scar, umbilicus (navel), diaphragm 26, Other disease 'A. Chicken pox 8. German Measles C. Mumps D. Measles [QUESTIONS ON FAMILY ILLNESSES [25. Have any of your family members, parents siblings, grandparents or relatives, whether living or dead lever suffered from any of the following conditions? fA. Heart disease Ib. High Blood Pressure IC. Kidney disease D.Stroke. IE Diabetes Melitus F. Enilepsy IG. asthma Hi. Hepatitis 8 I Arthritis [Allergies (Specify what type: Drugs or Food) Ik. Cancer (Specify type) DECLARATIONS AND SIGNATURES \We hereby declare that we have fully understood the questions in the declaration and further declare that the answers given by me/us to all the questions in the form are true and complete in every respect and that I/We have not withheld any material information or suppressed any material fact that may in any way affect my acceptance or enrolment into this University. Furthermore, any false information given in relation to this document will not hold the University liable for any consequences of the falsity of the declaration. Date Signature of applicant over Printed name Signature of Physician over Printed name Ucense no,