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    Hso G Medical Examination Form

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    orionsruler
    This document is a physical examination form for a university student. It contains fields for the student's contact information, medical history, physical exam findings, diagnosis, and recommendations from the examining physician. The student agrees to undergo the physical exam and have their health information kept confidential by the university for 5 years.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Hso G Medical Examination Form

    Uploaded by

    orionsruler
    104 views1 page
    This document is a physical examination form for a university student. It contains fields for the student's contact information, medical history, physical exam findings, diagnosis, and recommendations from the examining physician. The student agrees to undergo the physical exam and have their health information kept confidential by the university for 5 years.

    Original Title

    Hso g Medical Examination Form

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    © © All Rights Reserved

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    This document is a physical examination form for a university student. It contains fields for the student's contact information, medical history, physical exam findings, diagnosis, and recommendations from the examining physician. The student agrees to undergo the physical exam and have their health information kept confidential by the university for 5 years.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    104 views1 page

    Hso G Medical Examination Form

    Uploaded by

    orionsruler
    This document is a physical examination form for a university student. It contains fields for the student's contact information, medical history, physical exam findings, diagnosis, and recommendations from the examining physician. The student agrees to undergo the physical exam and have their health information kept confidential by the university for 5 years.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    ________________________

    Examining Physician
    Health Services Office

    2401 Taft Avenue, 1004 Manila, Philippines Tel: (632) 536-0252 | Trunk Line: (632) 524-4611 loc. 221


    DATE: _________________
    SCHOOL YEAR: __________
    ID NUMBER: _____________________ COLLEGE: _____________
    LAST NAME: _____________________ FIRST NAME: ______________________ M.I._______
    CONTACT#: ________________
    CONTACT PERSON IN CASE OF EMERGENCY: ________________________ RELATIONSHIP: ________
    CONTACT#: _______________________
    AUTHORITY TO CONDUCT MEDICAL EXAMINATION
    I, __________________________, ____years old accept and understand that I am required to undergo a
    physical examination and chest x-ray to determine my fitness and well-being as a student. I fully
    understand that the results will be held as confidential medical records and will be used by the University for
    my care and treatment. My health information cannot be released to third persons except with my consent
    or unless the disclosure of the information is required by law. I also accept and understand that the
    procedures are requirements for the next academic year enrolment. I acknowledge that my medical records
    will be retained by the University for a period of 5 years from examination or health visit.
    ________________
    Signature of Student

    PHEX Consultation Details

    Physical Exam (to be filled up by a nurse/doctor)

    Medical History (updated)
    Blood Type_______________ 1.__________________ _
    Blood Pressure____________ 2._______________________
    Resp. Rate_______________ 3._______________________
    Temperature______________ 4._______________________
    Pulse Rate________________
    Height (in inches) __________ Medications_______________
    Weight (in pounds) ________ __________________________
    BMI (to be computed by the system) _____ __________________________
    BMI Category-system-generated_______
    LMP (Female) ________ Social History
    Right Vision__________ ___ Smoking
    Left Vision ___________ ___ Drinking
    ___ Exercising
    Corrective Lens
    Findings
    Extremities
    MROTC_____________ ___ Left Handed
    MPE________________ ___ Right Handed

    Diagnosis
    ____________________
    ____________________
    ____________________

    Remarks/Recommendations
    Physically Fit

    For Clearance
    _________________________
    _________________ _________________________
    Assigned Nurse
    Physical
    Findings
    Head and
    Neck
    ___Normal
    __
    EENT
    ___Normal

    __
    Chest
    X-ray
    ___Normal

    Lungs
    ___Normal

    Neurologic
    ___Normal

    Breast
    ___Normal
    Heart
    ___Normal

    Skin
    ___Normal

    Abnormal Findings







    Abdomen
    ___Normal

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