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Health Appraisal Record: I. Personal Data: II. Physical and Medical Examination

The health appraisal record contains personal information for a 16-year-old male patient and documents the results of a physical examination, including height, weight, and blood pressure. It also includes a questionnaire regarding the patient's medical history and current health conditions, as well as questions about exercise habits, smoking, and alcohol use. The document certifies that the patient provided accurate answers to the health questionnaire.

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JA Berzabal
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217 views

Health Appraisal Record: I. Personal Data: II. Physical and Medical Examination

The health appraisal record contains personal information for a 16-year-old male patient and documents the results of a physical examination, including height, weight, and blood pressure. It also includes a questionnaire regarding the patient's medical history and current health conditions, as well as questions about exercise habits, smoking, and alcohol use. The document certifies that the patient provided accurate answers to the health questionnaire.

Uploaded by

JA Berzabal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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HEALTH APPRAISAL RECORD

I. PERSONAL DATA:
Name: Rainier John I. Berzabal Gender: Male Age: 16
II. PHYSICAL AND MEDICAL EXAMINATION
Height: ________ Weight: _____________
Resting Pulse Rate: _________ Blood Type: _________
Date of Last Medication: __________________________
III. QUESTIONNAIRE:
To be further of assistance to you, please answer and/or check the answer of the following questions.
Any hospitalization/ surgery since last medical examination? (YES)____(NO)____
if YES, please indicate nature of injury/ injuries? ______________________
1. Any injury sustained last medical examination? YES____ NO_____
What was the nature of injury/ injuries? _______________________
2. Have you had any of the following:
a. Chest Pain or difficulty of breathing on physical exertion? YES_____NO_____
b. Frequent dizziness or fainting spells? YES_____NO_____
c. Asthma? YES_____ NO_____
d. Other lung disease? YES_____NO_____
e. Diabetes? YES _____NO_____
f. High Blood Pressure? YES_____NO_____
g. Anemia? YES_____NO_____
h. Kidney Trouble/ Disease? YES_____NO_____
i. Arthritis? YES_____NO_____
j. Gout? YES_____NO_____
k. Dislocation? YES_____NO_____
If yes please indicate what part of the body_________
j. fractures? YES____NO_____
3. At present, do you have lumbar/lower back pain? YES___ _NO_____
4. Other ailments which you have at present that may in a way restrict your physical activity? Please
specify___________________
5. Are you now under treatment? YES____NO____
6. Do you engage in regular exercise? YES____NO____
7. How often do you exercise? ________________
8. How long do you exercise? _________________
9. When was the last time you exercise? _________________
10.Do you smoke? YES___NO____
if yes, how many sticks a day? ____________________
11. Do you drink alcohol beverages? YES____NO____
if yes, how often _______________

I certify as to the correctness of the answers to the above questions.


______________________________________ _________________________
Name and Signature of Students Date
______________________________________ _________________________
ACTIVITY 1: Health Related Test
Instructions: Perform the following Health-Related Fitness Test with the supervision of one of your family
members. Record your score in a sample Self-Assessment card below.
1. Anthropometric Measurement
2. 3-Minute step-test
3. Hamstring and Hip Flexor Test
4. Zipper Test
5. Curl-Up
6. 90 degrees push up
7. Flexed arm support

Self-Assessment Card: Health-related fitness Status


Name: Rainier John I. Berzabal
Age: 16 Sex: Male
Weight: Height:
Classification
HEALTH RELATED FITNESS TEST SCORE Analysis/Implication
BMI
Waist Hip Ratio
3-minute step test
Push- Up
Curl-up
Flex arm *
Flexibility *
Zipper Test

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