(Clinic)
STUDENT HEALTH HISTORY FORM
Dumaguete City
Name:___________________________
Birthdate:________________________________
New:_______
Transferee:______
Returnee:_______
Course:______________
City:_________
Nickname:__________
Address :__________________
Male:_____
Female:______
Zip Code:__________________
Phone Number___________________
Day
Year
Fathers Occupation:__________________________
Mothers Occupation:_________________________
FAMILY HEALTH HISTORY
= If any relative has suffered any of the following. Please circle number and
indicate which relative.
Example:
1.) Epilepsy
2.) Headache
3.) Mental illness
(depression/anxiety/other)
4.) Kidney Disease
5.) Diabetes
6.) Thyroid Disease
7.) Hay fever (allergic rhinitis)
8.) Asthma
9.) Anemia
10.)
Bleed easily
11.)
12.)
13.)
14.)
15.)
16.)
17.)
18.)
19.)
20.)
Arthritis
Heart Disease
High Blood Pressure
High Cholesterol
Alcohol/ Drug addiction
Hepatitis/ HIV
Cancer
21.)
22.)
23.)
Tuberculosis
Osteoporosis
24.)
25.)
-Swollen ankles
-Palpitations
-with leakage
-with pain
Kidney stones
Student Signature: