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Clinic Form Student

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Erlene Linsangan
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15 views3 pages

Clinic Form Student

Uploaded by

Erlene Linsangan
Copyright
© © All Rights Reserved
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
Download as xlsx, pdf, or txt
Download as xlsx, pdf, or txt
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STUDENT MEDICAL FORM

I. PERSONAL INFORMATION
NAME: Linsangan Erlene Payla
Last Name First Name Middle Name Suffix

BIRTHDAY: 2 / 8 / 2001 AGE: 20 SEX: Female CIVIL STATUS: Single


mm dd yyyy

ADDRESS: 436 Brgy. Curva Bongabon, Nueva Ecija COURSE: BSBA


YEAR AND SECTION: 3B
FATHER'S NAME: Noel Z. Linsangan BLOOD TYPE: O
MOTHER'S NAME: Helen P. Linsangan CONTACT NUMBER: 639516005955

II. HEALTH INFORMATION


Do you have allergy/ies to: Y Food Insect Bites Medications
If yes, please indicate: slimy foods
Select conditions that are applicable to you:
Headache/Migraine Heart Conditions Hospitalization or Emergency visit
Fainting or blacking out High Blood Pressure Had any surgeries done
Head Injury Diabetes Fracture/dislocation in any bones
Dental Problems Chest Pain Problems Breathing/Coughing
Digestion Problems Asthma Treatments Excessive weight or gain loss
Bowel/Bladder Problems Urinary Problems Excessive Bleeding
Menstrual Problems Kidney Problems Uses glasses/contact lenses
Hearing/Speech Problems Tuberculosis Experiences seizures/convulsions
Others, please specify:

Do you smoke cigarettes? NO


If yes, how many pack/s a day can you finish?
Do you drink alcohol? NO
If yes, how often do you drink?
Do you have any history of drug addiction? NO

Does your family have any history of medical condition/s or ilness/es? YES
If yes, please explain briefly:

Father - Hypertension and Heart Complication

Please indicate medication taken, if any: (maintenance, vitamins, etc.)

Have you received any COVID-19 vaccine? YES


If yes, please specify details of your vaccine:
Vaccine Given (brand): Sinovac Date of first dose: / /
Date of second dose: / /
CONSENT

Please mark with (Y) the medication/s you ALLOW the School Nurse, or other qualified First-aider to administer, and
(N) the medication/s you DO NOT ALLOW to be administered:
Analgesics (ex. Paracetamol, Mefenamic Acid)
Para sa lagnat, pamamaga, o sakit ng katawan
Decongestant/Antihistamine (ex. Symdex-D)
Para sa sipon
Mucolytic/Expectorant/Anti-cough (ex. Ambroxol Trihydrate, Lagundi)
Para sa ubo
Antihistamine/Anti-allergy (ex. Chlorphenamine Maleate, Diphenhydramine HCl)
Para sa allergy
Anti-asthma nebules and tablets (ex. Salbutamol, Terbutaline Sulfate)
Para sa hika
Anti-vertigo (ex. Cinnarizine)
Para sa hilo
ACE Inhibitor (ex. Captopril)
Para sa mataas na presyon ng dugo
Anti-diarrheal (ex. Loperamide)
Para sa pagdudumi
Antispasmodic (ex. Dicycloverine Hydrochloride, Buscopan)
Para sa sakit at hilab ng tiyan
Vitamins and Minerals (ex. Ferrous Sulfate, Ascorbic Acid, Vit. B-Complex)

I agree to the administration of medications selected above, as the School Nurse or other qualified First-aider
deem necessary, and for medical/dental treatments to be administered in an emergency.

In the event of an emergency and the attending School Nurse/First-aider is unable to reach any of the contacts
given below, I hereby authorize the college and/or its employees to transport and give consent for me to receive
medical treatment at other healthcare facilities outside the college's supervision.

I understand that the college and its employees will not be held liable for any untoward incident that may happen
to me that are beyond control during work hours

In case of any emergencies, please contact:

NAME: PHONE NUMBER:


ADDRESS: RELATIONSHIP:

NAME: PHONE NUMBER:


ADDRESS: RELATIONSHIP:
Signature over printed name

Date

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