De La Salle University
RA
M E D I C A L A N D D E N TA L S E R V I C E S
Family Name
First Name
REL
FORM B
Middle Name
Date of Birth:
IG
DE LA
LLE UNIV SA
IO
M OR E S C U
M OR E S C U I OA L
SITY ER
U LT
RA
SITY ER
NI
Instructions for Physician: Fill out all sections of this form. To record data from patients Physical Examination, please tick appropriate boxes and fill-up the necessary information. Review of Systems: headache migraine dizziness blurring of vision visual loss hearing impairment nose bleeding tinnitus colds dyspnea tachypnea cough hemoptysis chest pain palpitations easily fatigued difficulty of breathing abdominal pain constipation diarrhea vomiting hyperacidity dysmenorrhea loss of appetite hematochezia melena hematemesis dysuria frequency neck pain back pain muscle pain joint pain Height (in inches) Weight (in pounds) Blood Type (please bring official result) LMP Right Yes Contact Lens Glasses Color Blind Normal Head and Neck EENT Chest / Lungs Breast
have been taken within the last six (6) months) Date
U LT
weakness deficit hallucination syncope convulsion depression fever chills malaise jaundice others
Physical Examination Blood Pressure Pulse Rate Resp. Rate Temperature Eye Examination Visual Acuity (using Snellen Chart) No
Left
Normal
Abnormal findings
In view of the students history and physical examination, is it your assessment that his / her health status is adequate for studies / school activities, without restrictions? Yes No If with restrictions, what are your recommendations? Other remarks: Diagnosis: Date: Physicians Name and Signature: License Number: Clinic Address:
Reminder: This form must be submitted to the University Clinic together with the official chest x-ray and blood type result.
Contact Number: