SOUTHEAST ASIAN FISHERIES DEVELOPMENT CENTER

AQUACULTURE DEPARTMENT
Tigbauan, Iloilo, Philippines

MEDICAL HISTORY:
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Past Medical History:
LAST NAME

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FIRST NAME

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Immunization History: MIDDLE NAME
DATE OF BIRTH:_______________________
ADDRESS:_____________________________
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Hospitalizations/Surgical History: AGE:________SEX:_________ C.S.:_________
BLOOD TYPE:__________________________
CONTACT NO.: _________________________
PASSPORT NO.:_________________________
SCHOOL/COMPANY/ADDRESS:
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FAMILY HISTORY: _____________________________________
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CONTACT NO.: ________________________
E-MAIL ADDRESS: ______________________
PLS. NOTIFY IN CASE OF EMERGENCY/
PERSONAL/SOCIAL HISTORY: CONTACT NO.: _________________________
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MENSTRUAL HISTORY: OBSTETRICS HISTORY: HEALTH INSURANCE PLAN/HMO:
_____________________________________
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PHYSICAL EXAMINATION: DATE: ________________________

BP CR RR Temp (˚C) Weight (kg) Height (cm) BMI

Vision Far Vision Near Vision Ishihara Color Vision

Unaided OD OS OD OS □ Adequate
Aided OD OS OD OS □ Inadequate

Yes Significant Findings Yes Significant Findings Yes Significant Findings

Skin Neck, Lymph Nodes, Anus, Rectum
Head, Neck, Scalp Thyroid
Eyes Breast, Axilla, Chest Genito-urinary System
Pupils Lungs Inguinals, Genitals
Ears Heart Extremities
Nose, Sinuses Abdomen Reflexes
Mouth, Throat Back Dental (Teeth/Gums)
PHYSICIAN’S Remarks/Assessment/Recommendations:

EXAMINING PHYSICIAN
LIC. NO.: ___________