HSS-OSA Form No.
01
01 June 2022
UNIVERSITY OF THE PHILIPPINES MINDANAO
Office of Student Affairs
HEALTH SERVICES SECTION
STUDENT’S MEDICAL HISTORY
A.Complete Medical History and Physical Examination is compulsory to complete your enrollment to the University
on the Philippines Mindanao and must be submitted as instructed below. PLEASE TYPE OR COMPLETE IN INK
THIS FORM. This record is to be treated confidentially.
Instruction: Fill out and insert accomplished form in the Medical Folder, which will be given to you during the
Physical and Dental Examination.
PLEASE KEEP THIS FORM NEAT AND CLEAN
Complete this form if you are enrolling during a regular semester and you are :
1. A beginning undergraduate or a beginning graduate student.
2. A transfer student from a regional campus or another school or university.
3. A re-entry student (undergraduate or graduate) who has been out of the University of the Philippines
Mindanao for at least one semester.
B. Do not complete this form if you are enrolling for summer class only.
PERSONAL DATA:
Student No. Last Name First Name Middle Name Sex Civil Status
Complete
Address:_______________________________________________________________________________________
Student’s Contact No.________________ Email Address:____________________Religion: ____________________
Date of Birth: _________________Place of Birth:_____________________________________ Age:____________
If cultural minority, specify: _______________________________________________________________________
College: ________________________________ Course : ______________________________________________
Classification: Freshman ______ Sophomore _______ Junior _______ Senior ______
Graduate _______ Special __________ Non-degree _______
Name of Parent/Guardian/Spouse: ______________________________________________________________
Complete Home Address: _____________________________________________Contact No. _____________
Complete Employment Address/Position/Tel. No. _________________________________________________
__________________________________________________________________________________________
FAMILY HISTORY: (Kindly check your answer to the following)
Mother: Living _______ Deceased _______ Cause of Death __________________________________________
Father: Living ________ Deceased _______ Cause of Death __________________________________________
Has any member of your family attended any Campus of the University of the Philippines?
Yes ____No ____Relation _____________________ UP Campus ________________ When _______________
PHILHEALTH MEMBERSHIP: (Please check)
Mother : Member Yes ______ No _________
Father : Member Yes ______ No _________
Student : Member _____ Dependent ________
Covid-19 Vaccination Status:
Vaccination Shot Brand of Vaccine Date of Place Remarks
Vaccination
1st Dose
2nd Dose
1st Booster
2nd Booster
None ( State the
reason)
Among your blood relatives, is there history of any of the following:
Disease Yes No Relationship Disease Yes No Relationship
Asthma Kidney trouble
Cancer Mental disorder
Convulsion Rheumatism
Diabetes Skin disorder
Digestive problems Bleeding tendencies
Heart problems Stroke
High blood pressure Tuberculosis
Have you ever been diagnosed with any of the following?
Disease Age Disease Age Disease Age
Anemia High blood pressure Rheumatic fever
Amoebiasis Influenza Skin disease (specify)
Chicken pox Dysmenorrhea Small pox
Convulsions Joint pains Syphilis
Diabetes Kidney diseases Thyroid disorder
Diphtheria Malaria Tonsillitis
Ear disorder/defect Measles Tuberculosis
Eye disorder/defect Mumps Typhoid fever
Gonorrhea Mental problems Ulcer (peptic/gastric)
Heart disease Pleurisy Skin ulcers
Hepatitis Pneumonia Whooping cough
Hernia Poliomyelitis Other conditions
Have you ever had or do you now have any of the following? Please check.
Symptom Yes No Symptom Yes No Symptom Yes No
Asthma attacks Frequent urination Nausea(frequent)
Chest pain Fainting spells Nosebleed
Cough Hay fever Rapid pulse rate
COVID-19 Headache Palpitations
Depression Indigestion Sore throat
Diarrhea Influenza Swollen feet
Difficulty breathing Insomnia Vomiting
Dizziness Joint pains Others:
Eczema Loss of weight
If your answer is “Yes” on the above mentioned symptoms, give details (add paper if needed)
___________________________________________________________________________________________
Medical and surgical History, serious illness, operation, fractures, injuries, and accident. Please give details (add
paper if needed)
___________________________________________________________________________________________
If your tonsils have been removed, indicate condition of health since operation. Improved ______ Same______ worse
______.
Do you worry too much? _______ Does your self-consciousness interfere with your getting along easily? _________
Are you bothered by a feeling that people are watching or talking about you? _________________
Are you allergic to any food, serum, drug, or medicines (penicillin, antitoxins, etc.) No ____ Yes _______If so, list:
______________________________________________________________________________________________
Date of last eye check-up: __________________________ Date of Last Eye check-up: _______________________
Do you wish to discuss any questions with regards to your health, family history, sex or personal habits with a
physician or nurse? No_______ Yes________
Are you taking any medicines at present? No ________ Yes _______ if so, what medicines?
______________________________________________________________________________________________
Do you have any special conditions or handicap, which requires special treatment, diet, or other special
consideration?No______Yes_____;ifso,what? ______________________________________________________
FEMALE STUDENT TO ANSWER THE FOLLOWING:
Menstruation: has begun or age of onset (menarche) _____________________Periods: ____________________
Occurs every ___________ to ____________ days. Duration ____________ days.
Flow: Moderate ___________ Excessive ____________ Scanty ______________.
Dysmenorrhea ___________, Incapacitating ___________. Bleeding between periods; No______ Yes________
Have you had any trouble with your breast? Lumps, tumor, surgery, etc. No_________ Yes _______ If so, kindly
explain: _____________________________________________________________________________________.
MALE STUDENT TO ANSWER THE FOLLOWING:
Have you now or had hernia or rupture? Yes ____________________ No ___________________
Have you had any trouble with your testicles (infection, injury, surgery, etc)? No ______ Yes _______
Have you had any trouble in urinating? Yes ____________ No __________________
IMMUNIZATIONS RECEIVED: ( please check if complete; specify number of shots if not completed)
______ DPT (complete) ________ OPV (complete) _______BCG _______Measles
______MMR _______chicken pox _______Hepatitis-B (complete) _______Hepatitis-A
______Tetanus toxoid (complete) Others: (specify) ___________________________________
DECLARATION AND DATA SUBJECT CONSENT FORM
I certify that the above history is true to the best of my knowledge. I have fully disclosed all medical conditions that may
affect my performance as a student of the University.
Also understand that the UP Mindanao Health Services Section will not be liable to any untoward incident that may arise
due to the deferral of the physical examination and other laboratory test.
In compliance with the Data Privacy Act of 2012 and its Implementing Rules and Regulation, I voluntarily consent to the
collection, processing, and the storage of my personal and heal information for the purpose/s of health assessment,
treatment, and / or research (following research ethics guidelines) for the improvement of health care services.
________________________________________
SIGNATURE OVER PRINTED NAME / DATE
NOTE : Both student and guardian will affix their signature,
if the former is aged bellow 18 years old
HSS-OSA Form No. 02
April 2017
HEALTH SERVICES SECTION
UNIVERSITY OF THE PHILIPPINES MINDANAO
Mintal, Tugbok District, Davao City
PHYSICAL EXAMINATION
Print
NAME:_________________________________________ AGE_______Civil Status_______
(last) (first) (middle)
STUDENT NO.__________________________COURSE:_____________________________
ADDRESS_______________________________________ TEL NO._____________________
PRESENT STATUS
(Don’t write on this part. To be filled out by University Physician)
PHYSICAL: Height:__________cm Weight:______lbs.
Posture: Lordotic______; Scoliotic_____; Athletic______
HEAD AND FACE
Far Near Far Near
Eyes: Right: General condition_______vision______________ with glasses______________
Left:Generalcondition_________ vision________________with glasses_______________
Gross imbalance___________Color vision__________ Pupil Reflexes________________
Ears: Right: Cerumen: Excessive______Impacted_____, eardrum_______discharge_________
Left: Cerumen: Excessive______ Impacted_______, eardrum_____discharge_______
Nose: (check): Chronic infection, polyps, dev.septum, spur, and hypertrophied
turbinate____________Discharge: serious,purulent, foul________________________________
MOUTH AND THROAT:
Tongue: Coated, Swollen, Atrophied, dehydrated, deviates from left to right, tremors,and
others_________________________________________________________________
Palate: Normal cleft, ulcerated, others_______________________________________________
Pharynx: Inflamed, discharges, ulcerated, granules____________________________________
Tonsils (In Normal, hypertrophied, septic)___________________________________________
Cervical adenopathy: No, Yes, location___________________ (out: Nonseptic-tag, Septic-tag)
Neck: Abnormal pulsation, scars, cysts:______________________________________________
Thyroid: Normal, enlarged---Slightly, moderately, marked, operated, defused, nodular soft,
medium, hard, others ____________________________________________________
DENTAL EXAMINATION
Teeth:General___________________________Gingival condition_______________________
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
R------------------------R L-------------------------L
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Indicate
D-Decayed restorable teeth;X-missing/Extracted :F-filled/restored;E-forextraction/non-restorable
Prosthetic dental appliances_______________________________________________________
Other findings/Recommendations__________________________________________________
Examined by:_______________________ PTR NO.______________Date:_________
Dentist’s name & signature
GENERAL MEDICAL:
General Health Appearance: Excellent, good, fair, poor:_______________________________
Nutrition: Over, under, good, fair: _________________________________________________
Constitution Type: Asthenic, athletic, pyknic, dysplastic, mixed__________________________
Lymph Nodes: enlarge, tender (cervical, axillary, epithrochlear, inguinal),__________________
Others: _______________________________________________________________________
Chest: _____________________________________________________________________________
Lungs: Respiration/min _______ X-ray findings:____________________________________
Heart: Pulse rate/min: sitting: ______; 1 min after exercise______; 5mins. after__________
Breast: _______________________________________________________________________
Blood Pressure:______________________Temperature:__________________
SURGERY AND G.U.:
Abdomen________________________Scar: Yes,______ Location_________ None_______
Hernia (direct, indirect, and complete) Anus: Fistulas, Hemorrhoids, others_________________
Genitalia: Discharges, scar, tumor, phimosis, testicular atrophy, varicocele, undescended
testis,hydrocele________________________________________________________
Spine:Kyphosis, Lordosis, Limited motion, tenderness__________________________________
Extremities: Edema, varicose, atrophy, hypertrophy, paralysis, others______________________
DERMATOLOGY:
Skin: General: Anhydrosis, hyperhidrosis, jaundice, cyanosis, pallor, pigmentation___________
Local: Petechiae, edema, callus, pigmented naevi_________________________________
Skin disease_________________________________Location___________________________
Vaccination Mark (location)______________________________________________________
CLASSIFICATION: Health Rating: A B C D
Activity: I - Unlimited; II- Unlimited with Observation;
III- Restricted and Corrective; IV -Reconstructive; V -No activity
=====================================================================
Abnormalities Found Medical Advice / Presriptions
Medical examination
The above findings are certified true and correct at the time and date of examination.
Examined By:__________________________________
Physician’s name & Signature
PTR NO.:_____________________________________
Date & Place: __________________________________
