UMak-MDO-QF2 [rev4Feb2022]

UNIVERSITY OF MAKATI ID picture taken

J.P. Rizal Extension West Rembo, Makati City
within the last 6
Medical and Dental Office months
3.5 cm. X 4.5
Medical and Dental Record cm (passport
size)
Date: Computer
generated or
Department:
photocopied picture
Name: Age: Date of Birth:
Surname (Apelyido) First Name Middle Name (Gitnang Pangalan) (Edad) (Araw ng kapanganakan)
(Pangalan)

Address:
(Lot Blk No.) (Street) (Barangay) (Municipality/ City)

Gender/Kasarian : Male Female Civil Status: Single

Married Widow Others:

Person to be Notified in case of emergency: Relationship:

(Pangalan ng taong tatawagan kung may nangyari) (Kaugnayan sa Pasyente)
Address of Person to Notify:
(Tirahan ng taong tatawagan kung may nangyari)
Contact Number of Guardian:
(Numero ng taong tatawagan kung may nangyari)

MEDICAL HISTORY

Have you had any of the following diseases?

(Please Check the box/es)
Blood Type: Covid Vax Status:

Allergy (food/Meds) Kidney Disease Bronchial Asthma (Hika)

Epilepsy (Pangingisay) Arthritis
Mumps (Beke) Hypertension Heart Disease
Typhoid Fever(Tipus) Pneumonia
Measles (Tigdas) Diabetes Mellitus Dengue Fever Tuberculosis
Malaria
Chicken Pox (Bulutong) Hepa A ( ) Hepa B ( ) Liver Disease ( ) Surgical Operations:
Do not write below this line, to be filled up by Medical Personnel only
DENTAL ASSESSMENT/ EXAMINATION

LEGEND:
C = Carries
TX = For Extraction
RCT = Root Canal Treatment
Am = Amalgam
TF = Temporary Filling
CF = Composite Filling
P = Pontic
PJC = (Porcelain/Plastic) Jacket Crown

Remarks:

University Dentist Signature

MEDICAL ASSESSSMENT/ EXAMINATION

Laboratories Submitted
Chest Xray: Height: Weight:
CBC:
Urinalysis: BMI:

Fecalysis:
w/C. L. ( )
Neuro-Psych: V/A: OD ( R ) OS ( L ) Drug Test:

Others:
Remarks:

Legend: Blank = No findings

BP:

Univer
sity
Physic
ian
Signat
ure
 Medical and Dental Record
DATE CHIEF COMPLAINS/ DIAGNOSIS TREATMENT/ REMARKS