PERSONAL HEALTH ASSESSMENT

PERSONAL INFORMATION:
FULLNAME: PhilHEALTH NO.:

ADDRESS: PHONE NO.:

DATE OF BIRTH: AGE: SEX: CIVIL STATUS: SPOUSE NAME:

HEALTH HISTORY:
PAST ILLNESS AND OPERATIONS: MEDICATIONS:

CARDIAC: RESPIRATORY: ENDOCRINE: GI/GU

 HYPERTENSION  ASTHMA  DIABETES  PEPTIC ULCER
 ANGINA  COPD o Diet controlled  RENAL FAILURE
 ATHEROSCLEROSIS  LUNG DISEASE o Oral hypoglycemics  MALABSORPTION
 CHD  PULMUNARY o Insulin controlled DISORDER
HYPERTENSION  GE REFLUX
 THYROID DISEASE
DO YOU SMOKE? ____________
HOW OFTEN: _______________
OTHER MEDICAL CONDITION OR IMPAIRMENTS:

VACCINATION: (INDICATE VACINNE & DATE OF VACCINATION) ALLERGY: (FOOD, MEDICATION, INSECTS, POLLEN)

FAMILY HISTORY:
Check the following disease that have appeared among parents, grandparents, and siblings:
 TUBERCULOSIS ____________________________  KIDNEY DISEASE __________________________
 DIABETES ___________________________  EMOTIONAL ILLNESS ______________________
 CANCER (TYPE) ____________________________  HIGHBLOOD PRESSURE _____________________
 SEIZURE DISORDER ________________________  PROBLEM WITH ALCOHOL/DRUGS ___________
 STROKE ___________________________  ASTHMA _______________________________
 HEART DISEASE ___________________________  OTHERS _________________________________

ASSESSMENT/COMMENT:

CONFORME : REFFERAL :

_________________________ ___________________________
PATIENT NAME & SIGNATURE

DATE: ______________________