Annex D

Central Philippine University

Jaro, Iloilo City

MEDICAL CLINIC
Medical History Form

Name: Shamea Joy Arroyo Castillo

Address: Sitio Bakulod, Carmelo, Banate Iloilo City
Birthdate: May 13-2001
Course and Level: BSN 3B
Sex: Female
Civil Status: Single
Parent /Guardian (or spouse): Donna Castillo Contact number: 09219839158

MEDICAL HISTORY

A. Allergies/ Reactions to Medications/Foods or Vaccinations?

Yes
No If yes, please specify ________

B. Present illnesses: (Please check any that apply to your health)

Bronchial Asthma
Diabetes
Heart Defect/ Disease
Hypertension
Allergies
Mental Health Conditions
Epilepsy/ Seizure Disorder
Bleeding/ Clotting Disorder
Hepatitis

C. Current Medications (Please list current medication/maintenance meds if there are

any)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

D. Immunization:
VACCINE DATE RECEIVED

Dose 1 Dose 2 Booster Booster#2 Booster#3

COVID-19 ✔️ ✔️
Influenza (Flu)
Pneumonia
Hepatitis B ✔️
Others: (Please list
immunization
received)
PAST MEDICAL HISTORY

A. Hospitalizations and Dates:_______________________________________________

_____________________________________________________________________

Annex D

B. Operation and Dates: ___________________________________________________

_____________________________________________________________________

C. Serious Injuries and Dates: ______________________________________________

_____________________________________________________________________

FAMILY HISTORY
Please check any family history of the following: (indicate who has/had the
conditions)
Alcoholism/ Drug Abuse Heart disease or
stroke
Psychiatric Disorder Thyroid Disease
High Blood pressure Bleeding/ Clotting
problem
Asthma/ Hay fever/ Eczema Inherited/ Genetic disease

PERSONAL HISTORY

Do you smoke? Yes No

Do you drink intoxicating drinks? Yes No
Have you taken illegal drugs? Yes No

Emergency Contact Information

In case of emergency, who may we contact for you?

Name: Donna Castillo

Cellphone number: 09352464214
Home phone number: 09219839158
Workplace phone number: ___________________________________________
Address: Sitio Bakulod Carmelo Banate Iloilo City
This person’s relation to you: Mother