Republic of the Philippines

Paste
CENTRAL MINDANAO UNIVERSITY 2”x2”picture
Musuan, Maramag, Bukidnon here

HEALTH SERVICES UNIT

STUDENT OPD HEALTH RECORD HOSPITAL RECORD NUMBER

NAME Age Birthday Gender Status

Surname First Name Middle Name
Home Address Religion Contact No.
Father Occupation Contact No.
Surname First Name Middle Name
Mother Occupation Contact No.
Maiden Name Surname First Name Middle Name

Heredofamilial disease present among family members ( put a check mark if present )
Hypertension Allergy Bronchial asthma Others please specify :
Diabetes mellitus Cancer Psychological disorders

Personnal history
Allergies: Food Medications/Drugs
Surgical procedures(Operation) Date(s) Operated
Disability:
Present medical problem (s) Bronchial asthma Hyperacidity Cardiac problem Others
******** For Females only
First day of Last menstruation Frequency Regular (every month ) Irregular ( no definite schedule)
Have you ever been pregnant No Yes If yes, how many times?

DECLARATION AND DATA PRIVACY CONSENT FORM

I submit that all the information is accurate and complete. I understand that withholding any relevant medical information, any
misrepresentation of facts or misleading information given by me may be used as ground for the filling of cases against me in accordance
with the law. I voluntarily and freely consent to the collection, generation, use, processing, storage, retention and disposal (using the DOH
Record Disposition Schedule) of my personal information by the CMU-Hospital for the purpose of health management, statistical report &
data sharing to other government agencies such as DOH, PHIC and RHU and other related agencies.

________________________________ __________________ _____________________________

Signature over Printed Name of Student Signature over Printed Name of Parent/Guardian (for minor)

Date * Time Vital Signs History * Physical Examination * Laboratory results Diagnosis Treatment
T: For P.E.
P:
R: HBsAG -
BP CXR -
Wt:
Ht:
Snellen Reading: L-
R-
Ishihara Reading: L-
R-

CMU-F-4-HSU-003 03 June 2019 Rev.0

Snellen Reading: L-