Republic of the Philippines

UNIVERSITY OF RIZAL SYSTEM

Province of Rizal
MEDICAL - DENTAL UNIT

MEDICAL RECORD
Date: ____________________
AY: 20________ -20 ________

Name: Age: Sex:

(Surname, Given Name, M.I.)
Address:
Parents/Guardian: Contact No. of Parents/Guardians:
College of Course:
Height: Weight: BMI: BP: PR: Temp.:
HEENT:
Chest/Lungs:
Heart:
Abdomen:
Extremities

___ Bronchial Asthma ____ Surgery ______ Epilepsy _____ Allergies ______ Hernia _____ Heart
Dse.
Meds: LMP: ________________

Remarks: ________________________________________________________________________________________
Recommendation/s: ________________________________________________________________________________

______________________________
______________________________
Patient’s Signature Medical Officer III / Nurse II

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URS-AF-GE-MED-F-2017-05 Rev. 00 Effectivity Date: August 15, 2017
Date Complaint/s Finding/s Diagnosis Treatment/Plan

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