MEDICAL CERTIFICATE

For Enrollment
(for Freshmen, Returnees, and Transferees)

INSTRUCTIONS

1. Undergo the medical diagnostic tests (CBC, Urinalysis, and Chest X-ray) at any preferred diagnostic laboratory.
The diagnostic request form to be presented to the laboratory is found below.
2. Undergo Physical Examination at any preferred clinic and present results of the diagnostic tests to the
physician performing the physical examination.
3. The Patient Health Record (Page 1) should be accomplished by the Student or Legal Guardian. Please attach
one (1) copy of 2x2” ID (taken within the last 6 months) on the form.
4. The Medical Certificate (Page 2) should be accomplished by a licensed government/private physician.
5. The following medical documents must be submitted to the LNU Health Services Office (HSO) thru e-mail:
healthservices@lnu.edu.ph on or before August 12, 2022.
5.1 Accomplished Patient Health Record and Medical Certificate (Page 1 and 2)
5.2 Copy of the results of the diagnostic tests
5.3 Copy of the Vaccination Card/Certificate (including booster dose/s, if any)
6. The hard copies of the medical documents must be submitted onsite to the LNU HSO at your convenient time,
on or before September 30, 2022, Monday to Friday, 8 am to 5 pm.
7. For any inquiries, please contact the LNU HSO at 0917-722-0270 / 0945-885-7602.

STUDENT DEVELOPMENT AND AUXILIARY SERVICES

HEALTH SERVICES OFFICE

Name: ____________________________________________ Date: ______________

Age: ____ Sex: ____ Address: _________________________________________________

Request for Diagnostic Tests:

1. Complete Blood Count with Bood & Rh Typing

2. Urinalysis
3. Chest X-ray, PA view

Purpose: for School Enrollment

 CLINIC NO. (To be accomplished by the HSO Staff)
LEYTE NORMAL UNIVERSITY
HEALTH SERVICES OFFICE - -
Tacloban City

PATIENT HEALTH RECORD

Instructions: Please accomplish this form carefully in blue or black ink. ALL INFORMATION PROVIDED WILL BE TREATED AS CONFIDENTIAL BY ALL STAFF.
PERSONAL INFORMATION
NAME:
(Surname) (First Name) (Middle Name)

DATE OF BIRTH: SEX: ( ) Female ( ) Male GENDER IDENTITY(Optional):

CIVIL STATUS: CITIZENSHIP: RELIGION:
PATIENT CATEGORY: Please check appropriate ( ).
( ) ILS ( ) CoEd ( ) CME ( ) CAS ( ) Graduate Student ( ) Employee ( ) Other________
GRADE/PROGRAM/YR-SEC: OFFICE/YEAR EMPLOYED AT LNU:
(For Students) (For Employees)

HOME ADDRESS:
E-MAIL ADDRESS: CONTACT NO.:
NAME & ADDRESS OF SCHOOL LAST ATTENDED:

PERSON TO CONTACT IN CASE OF EMERGENCY:

RELATION: CONTACT NO.:
FAMILY HISTORY (Please check (✓)the diseases/illnesses any of your relative (up to first degree) have had, otherwise, put a cross (X) mark.

( ) Bronchial Asthma ( ) Diabetes ( ) Tuberculosis

( ) Hypertension ( ) Kidney Disease ( ) Mental Illness
( ) Heart Disease ( ) Cancer ( ) Others (Please Specify) ________________________
( ) Stroke/Cerebrovascular Accident ( ) Allergies ________________________________
PAST MEDICAL HISTORY
(Please check (✓)the diseases/illnesses which you already have had and write the age at which you had it on the space provided, otherwise, put a cross (X) mark)

( ) Chickenpox ____ ( ) Hepatitis ____ ( ) Bronchial Asthma ____

( ) Measles ____ ( ) Tuberculosis ____ ( ) Dengue ____
( ) Mumps ____ ( ) Pneumonia ____ ( ) Epilepsy (Convulsion) ____
( ) Poliomyelitis ____ ( ) Typhoid Fever ____ ( ) Diabetes ____
( ) Hypertension ____
( ) Allergy (Please specify the triggering factors/allergen) ______________ ( ) Mental Illness ____
_________________________________________________
( ) Previous Hospitalizations (Please specify) _______________________________________________________________
( ) Previous Surgical Operations (Please specify) ___________________________________________________________
Other illnesses: ____________________________________________________________________________________
PSYCHOSOCIAL HISTORY
Cigarette Smoker? Yes ( ) No ( ) Alcoholic Beverage Drinker? Yes ( ) No ( )
If yes, If yes,
for how long? _________ how often? _________________________
how many sticks do you consume per day? ______ how many glass per session? ___________
OBSTETRIC HISTORY (For Women Only)
Previous Pregnancy Yes ( ) No ( ) Date of Last Menstrual Period (First Day): __________
If Yes, Number of Pregnancies: _________ No. of days __________
Date of Last Delivery: ________________

ID taken within
the last 6 months,
2 x 2in

(PLEASE PASTE)
Printed Name and Signature of Patient or Legal Guardian
Date:
F-HSO-001 (09-02-19) Page 1 of 2
MEDICAL CERTIFICATE
(To be accomplished by a licensed government/private physician)
DATE/TIME: CHIEF COMPLAINT
PATIENT’S AGE:
VITAL SIGNS HISTORY OF PRESENT ILLNESS
WEIGHT (kg)
HEIGHT (cm)
BMI (kg/m2)
BP (mmHg)
HR (bpm)
RR (cpm)
Temp (°C)
IMMUNIZATION HISTORY
COVID-19 Vaccine:

PHYSICAL EXAMINATION
Gen. Status
Others:
Skin

Head

Eyes

Ears

Nose
OTHER REMARKS
Throat

Neck

Chest & Lungs

Heart

Abdomen

Extremities

Other:

ASSESSMENT

RECOMMENDATION

____________________________________
Name and Signature of Examining Physician
Lic. No. _____________
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