SULTAN KUDARAT STATE UNIVERSITY

HEALTH SERVICES DIVISION

ACCESS Campus EJC Montilla, Tacurong City

Persons with Disability Questionnaire

Name (Surname, First Name, M.I): Date:
Pls attach 1x1
Course/Year/Designation: Campus: ID Picture

Date of Birth: Age: Religion: Ethnic Group:

Sex: Civil Status: Blood Type:

Type of Disability (Pls Check): continuation

 Speech and Language

 Deaf or Hard of Hearing/Kapansanan sa
Impairment/Kapansanan sa Pananalita
Pandinig
 Visual Disability/Kapansanan sa Paningin
 Intellectual Disability/Kapansanan Pang-
Intelektwal)  Age-related macular degeneration.

 Learning Disability/Kapansanan sa  Cataract

Pagkatuto)  Diabetic Retinopathy

 Mental Disability/Mental na Kapansanan  Glaucoma

 Anxiety Disorder  Uncorrected refractive errors

 Mood Disorder  Others: ____________________
 Psychotic Disorder
 Other Disabilities, pls specify:
 Eating Disorder
________________________________
 Personality Disorder
 Dementia Cause of Disability:
 Autism
 Others: ___________________
 Acquired
 Physical Disability/Pisikal na Kapansanan
 Amputation  Cancer
 Paralysis  Chronic Illness
 Cerebral palsy
 Congenital/Inborn
 Stroke
 Multiple sclerosis  Injury
 Muscular dystrophy  Rare Disease
 Arthritis
 Autism
 Spinal cord injury
 Others: ___________________

Maintenance Medications if there’s any:

Any rehabilitation or treatment undergone or ongoing:

 SULTAN KUDARAT STATE UNIVERSITY
HEALTH SERVICES DIVISION
ACCESS Campus EJC Montilla, Tacurong City

Residence Address (House Number, Street, Barangay, Municipality, Province, Region):

Contact Details
Mobile Number: Email Address:

Name of Parents/Guardians: Contact Number:

Pls attach copy of PWD ID Card if available:

_____________________________

Name of Student/Personnel
(Signature above Printed Name)