ASIAN COLLEGE SCIENCE AND TECHNOLOGY

(Clinic)
STUDENT HEALTH HISTORY FORM
Dumaguete City

Name:___________________________
Birthdate:________________________________
New:_______
Transferee:______
Returnee:_______

Course:______________
City:_________

Nickname:__________

Address :__________________

Fathers Name :_________________________

Male:_____

Female:______

Zip Code:__________________
Phone Number___________________

Recent Enrollment in ACSAT: __________/________/_________

Month

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:

Diabetes- Maternal side (mother side)

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.)

Allergies: (Medications, foods, insects)

________________________________
Medication taken regularly: (Include: allergy shots, birth control, laxative,
vitamins, diet pills, anti-depressants, inhalers)
Medication
Dosage
Frequency
Surgeries/ Accidents/ Hospitalization
_________
_________
____________
______________________________
_________
_________
____________
______________________________
Please check if you had any of the following:
Symptoms or diseases:
Decreased Hearing
Ringing in Ear
Dizzy Spells
Vision Problems
Severe head injury/ concussion
Nosebleeds-recurrent
Sinus trouble
Sore throats-frequent
Hoarseness (difficult producing
sound when trying to speak)
prolonged
Hay fever / allergies
Pneumonia infection in lungs
Bronchitis/ chronic cough (8
weeks or more)
Asthma/ wheezing
Shortness of breath

-on exerting (with effort)

-lying flat (when on bed)

High blood pressure
Chest pain
Heart murmur (unusual sound
of heartbeat)

-Swollen ankles

-Palpitations

Foot/ leg pain

High cholesterol
Cold, numb feet
Hair loss
Loss of appetite- recent
Difficulty swallowing
Heart burn (painful burning in
chest)
Peptic ulcer
Persistent nausea/ vomiting
Abdominal pain-chronic
Jaundice/ hepatitis
Diarrhea
Constipation
Bloody or tarry stools
Hemorrhoid
Hernia
Bone fracture/ joint injury
Rashes
Arthritis
Back pain- recurrent
Urinating frequently

-with leakage

-with pain
Kidney stones

Blood in the urine

Sexually Transmitted Disease
Anemia
Diabetes
Seizures
Tremors/hand shaking
Numbness/tingling sensation
Headaches-frequent
Back pain-recurrent
Sleeping/concentration difficulty
Agitation
Phobias
Nervousness
Suicidal attempts
Rheumatic fever
Scarlet fever
Mumps
Measles
German measles
Tuberculosis
Malaria/tropical disease
History of alcohol/drug addiction
Eating disorder
Emotional/physical/sexual
abuse

Student Signature: