NAME OF STUDENT: ________________________________________________ BIRTHDATE: _______________

Last Name, First Name, M.I. mm/dd/yyyy

DATA SUBJECT CONSENT FORM

In compliance with the Data Privacy Act of 2012 and its Implementing Rules and Regulations, we execute
reasonable and appropriate security measures for the protection of personal data that we collect. Your
personal data will be collected, processed, and stored for the purpose/s of health assessment, treatment,
and/ or research (following research ethics guidelines) for the improvement of healthcare services. The
UP Health Service operates and holds personal data with utmost security and confidentiality.

I authorize and give my consent to the UP Health Service for the purpose/s stated above.
I understand that this consent will remain in full force until I revoke it in writing.

CONSENT FOR ASSESSMENT

PLEASE CHECK ONE:

For Minors (below 18 years of age):

I, ___________________________________________________ hereby voluntarily consent to

(Name of Parent/ Guardian)
the UP HEALTH SERVICE staff to conduct thorough physical examination and mental health
screening, to perform diagnostic procedure/s, and to administer treatment as deemed necessary
prior to my child’s university admission.

For those of Legal Age (18 years old and above):

I voluntarily consent to the UP HEALTH SERVICE staff to conduct thorough physical examination
and mental health screening, to perform diagnostic procedure/s, and to administer treatment as
deemed necessary prior to my university admission.

_______________________________________
Name and Signature of Student/
Date Signed

_______________________________________
Name and Signature of Parent or
Guardian/ Date Signed
Note: Both student and guardian will affix their
signatures, if the former is aged below 18 years old.
UPHS PEHA Form No. 2 UP Student No. _______________________
Revised 12/05/2022 College _____________________________

UNIVERSITY OF THE PHILIPPINES HEALTH SERVICE

PRE-ENROLLMENT HEALTH ASSESSMENT (PEHA)
A complete Medical History and Physical Examination is compulsory to complete your admission to the University of the Philippines (UP)
and must be on file, on or before your registration. This is the responsibility of the applicant and not your physician. Please type or
complete in BLACK OR BLUE ink. This form will be part of the Pre-Enrollment Medical files and will be treated with confidentiality. Prior
ethics approval will be solicited, in the event that UP may use relevant data for research purposes.

Important: Please bring accomplished form with you to the U.P. Health Service (UPHS), when you come for physical examination.

PLEASE KEEP THIS FORM NEAT AND CLEAN

You are required to fill-out this form if you are a/ an:

1 Newly admitted undergraduate, graduate, or post-graduate student of UP Diliman/ UPDEPP
2 New student admitted through other screening processes/ special progams (VAAS, Talent Test, etc.) 2"x2" or passport-size
3 Transfer student from a regional campus or another school or university colored ID photo
4 Old student but will be shifting to another degree program in UP Diliman taken within
the last
5 Returning student from Leave of Absence (LOA) or Absence Without Leave (AWOL) of at least two (2)
3 months
semesters, for whatever reason
6 Cross-enrolling from a regional campus or another school or university

Allergic to: Entrance Date to UP:

No known allergies

Please PRINT

Last Name First Name Full Middle Name Sex at Birth (SO)/ Gender Age

Civil Status: Single Married Widowed Divorced

Date of Birth: Birth Place:

College/ School of Registration in the University of the Philippines:

Freshman Graduate Post Graduate Transferee Cross-Registrant Returning from LOA/ AWOL

Home Address : Contact No.:

No. Street City Province Country

Address while in School: Contact No.:

Name of Parent/Guardian/Spouse:

Address: Contact No.:

Family History
Mother Living If deceased, Cause of death
(Age) (Age at death)
Father Living If deceased, Cause of death
(Age) (Age at death)

Among your blood relatives, is there a history of any of the following:

Yes No Relationship Yes No Relationship
Cancer Diabetes
Heart Disease Mental Disorder/Problem
High Blood Pressure Asthma or Hay Fever
Stroke Convulsions/Neurologic Problems
Tuberculosis Bleeding Problems/Blood Disorders
Kidney Disease Digestive disturbances
Arthritis/Rheumatism Skin Disease
UPHS PEHA Form No. 2 (back)

PERSONAL HISTORY. Give the appropriate AGE to which you had the following, otherwise write NA.
AGE AGE AGE
Anemia/Blood Disorder Hernia Poliomyelitis
Asthma High Blood Pressure Rheumatic Fever
Cancer Influenza A (H1N1) (indicate date) Skin Disease
Chickenpox Joint Pains/Arthritis Syphillis
Convulsions Kidney disease Thyroid Disease
Dengue Malaria Tonsilitis
Diabetes Measles Tuberculosis/Primary Complex
Diphtheria Mental Problem/Disorder Typhoid
Ear disease/defect Mumps Ulcer (peptic)
Eye disease/defect Neurologic Problem/Disorder Ulcer (skin)
Gonorrhea Pertussis (Whooping cough) COVID-19
Heart disease Pleurlsy Other conditions (please list)
Hepatitis (indicate type) Pneumonia

Have you ever had or do you have any of the folowing? Check each item YES or NO.
YES NO YES NO YES NO
Headaches (frequent) Sore throat (frequent) Diarrhea/Constipation (specify)
Dizziness (frequent) Chest pain Joint pains
Fainting/Loss of consciousness Back pain Muscle pain (frequent)
Insomnia Easily gets tired Frequent urination
Depressed mood (> 2 weeks) Difficulty of breathing Eczema/Skin problems
Eye/Visual problems Palpitations Fracture
Hearing problems Swelling of feet Accident/Injuries
Cough (> 2 weeks) Nausea (frequent) Hospitalization (reason)
Colds/Nasal Congestion Vomiting Operation (specify)
Fever (frequent/recurrent) Abdominal pain/discomfort Others, specify
Frequent early morning sneezing Loss of appetite
Nosebleed (frequent) Weight loss/gain (specify)
If answer is Yes to any, please give details

IMMUNIZATION RECORD Date given* Date given*

BCG Hepa A dose 1
Hepa B dose 1 dose 2
dose 2 Typhoid
dose 3 Others (specify)
Measles, Mumps, Rubella dose1 COVID-19
dose 2 Dose 1
Varicella dose 1 Dose 2
dose 2 Booster 1
Tdap Booster 2
* Please write ND if vaccine was given but date unrecalled; write NV for no vaccination.

Date of last dental check up ______________________________________ Date of last eye refraction _________________________________________________
Do you wish to discuss any question regarding your health, family history, sex or personal habit with a physician. Yes ______ No _______
Are you taking any medicines regularly? Yes ____ No ____ If so, what are these medicines? _____________________________________________________
Do you have any physical condition or handicap that requires special treatment, diet or other special consideration? Yes ______ No _______
FOR FEMALE STUDENTS:
Menstruation: Have not begun __________ or Age at onset __________ Periods occur every _______ to _______ days (interval between menses)
Duration: _____ days Flow: _____ Moderate _____ Excessive _____ Scanty Painful: _______ Incapacitating: _______
Last menstrual period (month and year): ________________________________
Have you had any trouble with your breasts, such as lumps, tumor, surgery? No _____ Yes _____. If so, give details ___________________________________

I certify that the above history is true to the best of my knowledge. I have fully disclosed all medical conditions that may affect
my performace as a student of the University.

Signature and Date

**Both student and guardian will affix their signatures, if the
former is BELOW 18 years old.
 MENTAL HEALTH SCREENING TOOL
Name:
Student No.: Date Accomplished (mm/dd/yyyy) :

This questionnaire is an important part of providing you with the best health care possible. Your HONEST
answers will help in understanding health problems that you may have. PLEASE ANSWER EVERY
QUESTION TO THE BEST OF YOUR ABILITY. Thank you.

Part A: Check the box corresponding to your answer.

Over the last 2 weeks, how often have you been bothered Several More than Nearly
Not at all
by any of the following problems? Days half days everyday

1. Feeling nervous anxiety, or on the edge

2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard ro sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
SCORE =

Part B: Check the box corresponding to your answer.

Over the last 2 weeks, how often have you been bothered Several More than Nearly
Not at all
by any of the following problems? Days half days everyday

1. Little interest or pleasure in doing things

2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
Feeling bad about yourself - or that you are a failure or
6.
have let yourself or your family down
Trouble concentrating on things such as reading the
7.
newspaper or watching television
Moving or speaking so slowly that other people could
have noticed? Or the opposite - being so fidgety or
8.
restless that you have been moving around a lot more
than usual.
Thoughts that you would be better off dead or hurting
9.
yourself in some way
SCORE =

If you checked off any problems on this questionnaire, how

difficult have these problems made it for you to do your
work, take care of things at home or get along with other
people?
UPHS PEHA Form 2C revised 2022

Name: Age: Sex: Civil Status:

Last First Middle

(Do not write below this line. To be filled out by the physician.)

Vital Signs and Anthropometric Measurements:

Pulse Rate: beats/min. Blood Pressure: mmHg Respiratory Rate: breaths/min. Temperature: °C

Height: cm. Weight: Kg. Body Mass Index: Asia-Pacific BMI Cut-Offs
[wt. in Kgs/ (ht. in m.)^2]
Underweight
___ Severe Thinness <16.00
General Health Appearance: Excellent Good Fair Poor ___ Moderate Thinness 16.00-16.99
___ Mild Thinness 17.00-18.49
Visual Acuity: Without Glasses With Glasses/ Contact Lens
___ Normal 18.50-22.99
FAR NEAR FAR NEAR ___ Overweight 23.00-24.90

Right: : : Obese
___ Obese 1 25.00-29.90
Left: : : ___ Obese 2 >30.00
Color Vision:

Please check the appropriate box whether findings are normal or abnormal for each organ/system; if with abnormal findings, please describe below:

Organ/ Systems: Normal Abnormal If abnormal, please describe findings

Skin
Head/ Scalp
Eyes
Ears
Nose
Mouth/ Oropharynx
Neck
Heart
Lungs
Back/ Spine
Abdomen
Extremities
Genito-urinary/Ano-rectal
Neurologic

Diagnostics/Laboratory Results:
Normal chest findings

CBC - within normal limits

UA - within normal limits

Activity: Unlimited Unlimited with Observation Restricted and Corrective Reconstructive No Activity

ASSESSMENT RECOMMENDATIONS

FIT TO ENROLL

Examined by:
PRC License No.:
Hospital Address:
Date Examined:
Dental Chart Revised 2023

UP HEALTH SERVICE Student/ OPD No. _______________

University of the Philippines ❑ Student
Diliman, Quezon City ❑ Faculty
❑ Employee
❑ Retired Faculty/Employee
Allergic to:
❑ Dependent
❑ Walk-in
DENTAL CLINIC
OUT-PATIENT RECORD

Last Name: Date of Birth: Age: Sex:

First Name: Contact No.:
Middle Name: School/ College/ Office/ Department:
Present Address:
Parent/ Guardian: Relationship: Occupation:
Permanent Address: Contact No.:

INTRAORAL EXAMINATION
STATUS
LEFT
RIGHT
55 54 53 52 51 61 62 63 64 65

TEMPORARY TEETH
P
E TREATMENT DONE
R
EXISTING CONDITION
M
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 A
N
E
N
T

T
E
E
T
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 H

TEMPORARY TEETH

STATUS
LEFT
RIGHT
85 84 83 82 81 71 72 73 74 75

LEGEND: CONDITION RESTORATIONS & PROSTHETICS SURGERY

✓ - Present Teeth Am - Amalgam Filling X - Extraction due to Caries
D - Decayed (Caries Indicated for Filling) Co - Composite Filling XO - Extraction due to Other Causes
M - Missing due to Caries JC - Jacket Crown
MO - Missing due to Other Causes Ab - Abutment
Im - Impacted Tooth
Att - Attachment X-ray Taken:
Rf - Root Fragment ___ Periapical (Tth No: _____)
Un - Unerupted P - Pontic
In - Inlay ___ Panoramic
Imp - Implant ___ Cephalometric
S - Sealants ___ Occlusal (Upper/ Lower)
Rm - Removable Denture ___ Others: ________________________

Other Clinical Findings Name of Dentist:

PRC License No.:
Date Examined:
Name of Student:
UP Student No.:

Dear Parent/ Guardian:

Please request the dentist who will perform your child's intraoral examination to fill out this form
as a summary of their recommendations. The student has the option to come to the UP Health
Service for any of the services and dental procedures mentioned below; most of which may be
availed of at discounted rates.

Pre-enrollment Health Assessment Committee

DENTAL RECOMMENDATION FORM

Patient is for:

Oral Prophylaxis
Restoration of tooth #
Extraction of tooth #
Others

Remarks: Teeth:
Gingiva:

Examined by Dentist:
PRC License No.:
Dental Clinic Address:
Date of Examination: