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Medinfosheet

The document is a student medical information sheet for Arellano University School of Law Medical & Dental Clinic that collects personal data, medical history, present illness, medications, allergies, family history, and social history from students. It requests information on common illnesses, hospitalizations, injuries, blood transfusions, COVID-19 status and vaccination, current medical problems, prescription medications, allergies, family medical conditions, smoking, drinking, and coffee consumption. Students are asked to sign and date the form to attest to the truth of the medical information provided.

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Danielle Ambrocio
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We take content rights seriously. If you suspect this is your content, claim it here.
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23 views1 page

Medinfosheet

The document is a student medical information sheet for Arellano University School of Law Medical & Dental Clinic that collects personal data, medical history, present illness, medications, allergies, family history, and social history from students. It requests information on common illnesses, hospitalizations, injuries, blood transfusions, COVID-19 status and vaccination, current medical problems, prescription medications, allergies, family medical conditions, smoking, drinking, and coffee consumption. Students are asked to sign and date the form to attest to the truth of the medical information provided.

Uploaded by

Danielle Ambrocio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ARELLANO UNIVERSITY

SCHOOL OF LAW
MEDICAL & DENTAL CLINIC
Taft Avenue Corner Menlo Street Pasay City
1x1 pic
84043089 to 93 loc 24
[email protected]
STUDENT MEDICAL INFORMATION SHEET
PERSONAL DATA:

STUDENT’S NAME: SURNAME GIVEN NAME MIDDLE NAME

STUDENT No. - FRESHMEN: TRANSFEREE: 0 REFRESHER:


YR. LEVEL: 1ST 2ND 3RD 4TH
BIRTHDAY: PLACE OF BIRTH: AGE:
CIVIL STATUS: SEX: RELIGION:
BLOOD TYPE: WEIGHT: HEIGHT: BMI:
CITY ADDRESS:
PROVINCIAL ADDRESS:
CONTACT NUMBER: EMAIL ADDRESS:
EMERGENCY CONTACT: RELATIONSHIP:
CONTACT NUMBER: ADDRESS:
MEDICAL HISTORY:
Have you had any common childhood illness Chicken pox Measles German Measles Mumps
Have you ever been hospitalized? No Yes Why: ____________________________
Have you had any serious injuries and/or broken bones? No Yes if yes, describe: ______________________
Have you ever received a blood transfusion? Not sure No Yes When: __________________
Have you been infected with COVID- 19? No Yes When: _____________________________
Have you received the Covid-19 Vaccine? No Yes Primary: ___________________________
1st Booster Shoot: _________ 2nd Booster Shot: _________
PRESENT ILLNESS:
Indicate whether you had a medical problem and/or surgery
_____________________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________________________________________
MEDICATIONS:
Are you currently taking any prescription and/or non-prescription medications No Yes, Pls. Indicate
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
___________________________________________________________________________________________________________
ALLERGY: FOOD: _______________________________________________________________
MEDICINES: ___________________________________________________________
OTHERS: ______________________________________________________________
FAMILY HISTORY:
HYPERTENSION DIABETES KIDNEY PROBLEM EENT
HEART AILMENT ASTHMA SKIN DISEASE OTHERS: _____________
SOCIAL HISTORY:
SMOKING FREQUENCY: ________________________
DRINKING
LIQUOR FREQUENCY: ________________________
COFFEE FREQUENCY: ________________________

I hereby attest to the truth of the foregoing medical information.


________________________________ ___________
Signature over Printed Name Date

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