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    Nicanor Reyes Medical Foundation: Far Eastern University

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    Audrey
    1. This document contains a risk assessment and evaluation form for Anna Paula San Pedro, a 20-year-old female student applying for an internship at Far Eastern University Nicanor Reyes Medical Foundation. 2. It collects her medical history, including any past or present illnesses, family history of illnesses, vaccinations, and a review of symptoms. 3. A physician conducted a physical exam, ordered laboratory tests, and provided an assessment and recommendations based on the information collected.

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    Nicanor Reyes Medical Foundation: Far Eastern University

    Uploaded by

    Audrey
    52 views2 pages
    1. This document contains a risk assessment and evaluation form for Anna Paula San Pedro, a 20-year-old female student applying for an internship at Far Eastern University Nicanor Reyes Medical Foundation. 2. It collects her medical history, including any past or present illnesses, family history of illnesses, vaccinations, and a review of symptoms. 3. A physician conducted a physical exam, ordered laboratory tests, and provided an assessment and recommendations based on the information collected.

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    nbuhji

    Original Title

    MED ASSES

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    1. This document contains a risk assessment and evaluation form for Anna Paula San Pedro, a 20-year-old female student applying for an internship at Far Eastern University Nicanor Reyes Medical Foundation. 2. It collects her medical history, including any past or present illnesses, family history of illnesses, vaccinations, and a review of symptoms. 3. A physician conducted a physical exam, ordered laboratory tests, and provided an assessment and recommendations based on the information collected.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    52 views2 pages

    Nicanor Reyes Medical Foundation: Far Eastern University

    Uploaded by

    Audrey
    1. This document contains a risk assessment and evaluation form for Anna Paula San Pedro, a 20-year-old female student applying for an internship at Far Eastern University Nicanor Reyes Medical Foundation. 2. It collects her medical history, including any past or present illnesses, family history of illnesses, vaccinations, and a review of symptoms. 3. A physician conducted a physical exam, ordered laboratory tests, and provided an assessment and recommendations based on the information collected.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    P.E. No.

    :0000001114
    Far Eastern University
    Nicanor Reyes Medical Foundation
    WORK INTERNSHIP/ RISK ASSESSMENT AND EVALUATION

    Name: (Surname, Given Name, M.I.) Age Sex Civil Status Religion Nationality

    SAN PEDRO, ANNA PAULA 20 FEMALE SINGLE ROMAN CATHOLIC FILIPINO


    Address Contact No.

    307 MANDALUYONG EXECUTIVE MANSIONS III G. ENRIQUEZ ST., BRGY. VERGARA MANDALUYONG 1551 09567108409
    School / Course Application No.

    MEDICINE MD1800662

    Check the appropriate box. Please fill in honestly and completely.


    PAST MEDICAL HISTORY YES NO REMARKS
    Do YOU have any history of:
    Hypertension/ Highblood /
    Diabetes /
    Asthma /
    Heart Disease /
    Seizure/ Convulsion/ Epilepsy /
    Mental or Psychological Illness /
    Pulmonary Tuberculosis /
    Previous Hospitalizations/Surgeries/Operations (including Minor operations) /
    Blurring of Vision or Error of Refraction /
    Any Medication/s taken daily /
    Chicken pox/Varicella /
    Tattoo/Identifying marks /
    Others /
    FAMILY HISTORY
    Do your FAMILY MEMBERS (grandparents, parents, siblings) have history of:
    Hypertension/ Highblood /
    Diabetes / Mother
    Heart Disease /
    Asthma / Brother
    Heart Attack before 40 years old /
    Sudden death/ Unknown Cause of Death /
    Seizure/ Convulsion/ Epilepsy /
    Stroke or Aneurysm /
    Mental Illness /
    Cancer /
    Others /
    PERSONAL AND SOCIAL HISTORY YES NO REMARKS
    Do you smoke? /
    Do you drink? /
    Do you have allergies?
    Allergies to food? /
    Allergies to drug/ medicines? /
    Others /
    OBSTETRICS AND GYNECOLOGIC HISTORY (FOR FEMALES ONLY)
    When was your last menstrual period? / January 05, 2017
    Do you have dysmenorrhea? /
    Are you expecting to be pregnant? /
    Is your menses regular? / Yes
    Any history of missed menses? /

    VACCINATION HISTORY : Please check all vaccines that you have received and specify the date or atleast the year.
    / Tetanus Toxoid Last dose: 2015 (Any booster within the last 10 years)
    / Varicella 2009 (Atleast 2 doses if you have not had a chickenpox)
    / MMR 1997 2004 2012 Booster 2014
    / Quadrivalent Flu Last dose: 2017 (given yearly)
    / Hepatitis B 1997 2004 2013 Booster 2015

    - print front page


    P.E. No.:0000001114

    REVIEW OF SYSTEMS
    AT PRESENT, Do you/ Do you have/ Do you feel...
    Fever? Headache? Dizziness? /
    Cough? Colds? Sore Throat? /
    Blurring of Vision? /
    Hearing Loss? /
    Body Pain? Easy Fatigability? /
    Chest Pain? /
    Shortness of Breath? Difficulty of Breathing? /
    Wake up at night due to difficulty of breathing or choking sensation? /
    Abdominal Pain? Diarrhea? Constipation? /
    Difficulty in urination? Frequent urination? /
    Edema ("Manas") /
    Rashes? Skin Changes? Cyst or Mass ("Bukol")? /
    Other Conditions not mentioned above? /

    I attest that I have answered above questions completely and truthfully.

    ANNA PAULA SAN PEDRO Date: JANUARY 21, 2018


    Signature over Printed Name

    To be completed by the physicians on duty:


    Vital Signs:
    BP: CR: RR: OS: OD:

    T: Ht: Wt: BMI: CV:

    Subjective Complaints:

    Laboratory Results: Remarks


    CBC Normal Abnormal
    Urinalysis Normal Abnormal
    Fecalysis Normal Abnormal
    Chest X-ray (PA) Normal Abnormal
    HBsAg Reactive Non-Reactive
    Anti-HBs Reactive Non-Reactive
    Drug Test Negative Positive

    Pertinent P.E.: Remarks


    HEENT Normal Abnormal
    Chest/Lungs Normal Abnormal
    Heart Normal Abnormal
    Abdomen Normal Abnormal
    Skin Normal Abnormal
    Extremities Normal Abnormal

    Assessment: Recommendations:

    Advise for: Final Result:


    Hepatitis B 1st dose 2nd dose 3rd dose Fit
    Varicella B 1st dose 2nd dose Fit w/ minor ailments
    TD Booster Pending due to
    MMR Unfit
    Quadrivalent Flu Others:
    for HBsAg the Hapatitis B Vaccine Series

    PHYSICIAN: DATE:

    - print back page

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