HEALTH INFORMATION SHEET FOR STUDENT Do not leave any item unanswered. Scan and send this Health Information Sheet to medical@pup.edu.ph PART I. STUDENT INFORMATION Name: Date: Address: School Year: __ Age:_Sex:__CivilStatus:__Course / College Blood Type: Parent'sName/Guardian: Landline: Cellphone: PART I. MEDICAL HISTORY 1. Do youneed medical attention orhas known medical iliness? || No | | Yes (Please check the following that apply and give more information as needed) | Asthma | Fainting Vision Problems Hearing Problems | Diabetes | HeartCondition | KidneyDisease Hearing Problems SeizureDisorder | Hyperventilation 1 Hemophilia Muscle Weakness/Paralysis | Migraine | Hypertension Others (Pls. Indicate) 2.Previous NoliYes Year: Hospitalization: Operation/Surgery: Nol iYes Year: 3. Additional Information for Students with Medical Conditions: Page 4of 11‘As a Parent/Guardian, | would lke to declare that my child/ward had history of allergies to the following: Food: Medicines: PART Ill. FAMILY HISTORY | Diabetes PTB Hypertension Cancer Others (Pls. Indicate) PART IV. PERSONAL HISTORY Cigarette Smoking Alcohol Drinking: Do you feel stressed: 1Yes (1 No Yes (1 No Yes (1 No I hereby state to the best of my knowledge, my answers to the above questions are complete and correct. By affixing my signature (Parent/Guardian), | am agreeing to the PUP Data Privacy Policy and giving my consent in the collection and processing of the student's name above his/her Personal Information in accordance thereto and be given medical and dental care by the PUP physician/Dentist. Signatureof Student Date Due to Community Quarantine, please be informed that Physical Examination for enrollment and submission of chest x-ray is temporarily deferred until further notice. Health Information Sheet Page Page Sof 1REFRESHER’S CAPACITY ADVANCEMENT PROGRAM (RECAP) APPLICATION INFORMATION FORM. Personal Information: Name Ager | Religion Present Address Provindal Address: Region: Date of Births Place of Birth Civil Status: Contact Information: Cellphone NoJs Tandline NoJs: Email Address: Father's Name: ‘Occupation: Mother's Maiden Name: ‘Occupation: ‘Spouse Name: (if applicable) Page 6 of 14‘Occupation oF Spouse: Name and Age of Name ‘Age Children: Siblings: Name ‘Age Page 7of 11Academic Information: Level Name of School Year Graduated Honors Received (fany) Elementary: High School: College Course: Graduate Studies: Program: Law School: ‘School last Attended: ‘Course in the School Last Attended: Page 8 of 1Eligibility Information: ‘Government/ Licensure Exam Passed Rating Date of Examination/ Conferment License Number Work Experience: (start with your current work, if any) Inclusive Dates Position Title Address ‘Department/Agency/Office/Company and Page 9 of 14Awards or Honors Received (other than academic awards/honors) College Affiliation/Membership in Association/Organization: Position Name and Addlress of Organization Inclusive Dates Page 10.014Have you been charged criminally, civilly or administratively? Yes No If your answer in the previous question is YES, please give details. Page 11 of 14