R epublic of the P hilippines

D epartment of Education
Region X
SCHOOLS DIVISION OF LANAO DEL NORTE
PIGCARANGAN, TUBOD, LANAO DEL NORTE

Medical History
1. Did you have any allergies? ___yes ____no. if yes, please identify.
___medicine
___pollens
___foods
___stinging insects
Others________________________________________________________________________

2. Do you have any medical conditions? ___yes ___no. If yes, please identify
___error of retraction
___asthma
___seizure
___heart problem
___anemia
___bleeding disorder
___hernia ( painful bulge in the groin area)
Others________________________________________________________________________

3. Have you ever had surgery / hospitalization? ____yes ___no. if yes please specify.
Surgey type: _____ minor _____ major.
Details______________________________________________________________________

4. Does any in your family have the following conditions:

___TB
___cancer, if yes, what type_________________________ present member with CA__________
___stroke/cvd/cva if yes:_______ paraphlegia_____ hemiphlegia.
___DN
___HPN
___depression
Others________________________________________________________________________

5. Exposure to cigarette/ vape / trad. Tobacco at home?___yes ___no.

VITAL SIGNS:
BP:_______ RR:_________ HR:________
MENSTRUAL CYCLE: _____REGULAR _______IRREGULAR ______DYSMENORRHEA______
CYCLE

NAME:________________________________________ AGE:______
SCHOOL:__________________________
DISRICT:________________________________ DATE:_______________________
EXAMINED BY:____________________________