Scribd Logo
Upload

Welcome to Scribd!

  • 2 views

    Student OPDHealth Card F 4 HSU 003

    Uploaded by

    Leo Christian Anthony Burlat

    Copyright:

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

    Student OPDHealth Card F 4 HSU 003

    Uploaded by

    Leo Christian Anthony Burlat
    2 views3 pages

    Copyright

    © © All Rights Reserved

    Available Formats

    XLSX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    2 views3 pages

    Student OPDHealth Card F 4 HSU 003

    Uploaded by

    Leo Christian Anthony Burlat

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    of 3

    Republic of the Philippines

    CENTRAL MINDANAO UNIVERSITY


    Musuan, Maramag, Bukidnon Paste 1 x 1
    picture here

    HEALTH SERVICES OFFICE

    STUDENT OPD HEALTH RECORD HOSPITAL RECORD NUMBER

    Name CUEVA, KRYSTEL EVE NICOLETTE N. Age 18 Birthday Gender F Status SINGLE
    Surname First Name Middle Name
    Home Address PUROK 3 PINILAYAN, QUEZON, BUKIDNON Religion ROMAN CATHOLIC Contact No.
    Father CUEVA, ROGER B. Occupation BARANGAY KAGAWAD Contact No.
    Surname First Name Middle Name
    Mother Maiden Name NAPOLE, MIRASOL T. Occupation TEACHER Contact No.
    Surname First Name Middle Name

    Heredofamilial disease present among family members ( put a check mark if present )
    Hypertension Allergy Bronchial asthma Others please specify :
    Diabetes mellitus Cancer Psychological disorders

    Personnal history
    Allergies: Medications/Drugs
    Past-Present Medical Surgical History Date(s) Operated

    Present medical problem (s) Bronchial asthma Hyperacidity Cardiac problem Others
    Disability: Medications/Drugs Maintenance
    ******** For Females only
    Date of Last menstruation Period Frequency Regular (every month ) Irregular ( no definite schedule)
    Have you ever been pregnant No Yes If yes, how many times?

    DECLARATION AND DATA PRIVACY CONSENT FORM


    I submit that all the information is accurate and complete. I understand that withholding any relevant medical information, any misrepresentation of facts or misleading
    information given by me may be used as ground for the filling of cases against me in accordance with the law. I voluntarily and freely consent to the collection, generation,
    use, processing, storage, retention and disposal (using the DOH Record Disposition Schedule) of my personal information by the CMU-Hospital for the purpose of health
    management, statistical report & data sharing to other government agencies such as DOH, PHIC and RHU and other related agencies.

    KRYSTEL EVE NICOLETTE N. CUEVA ________________MIRASOL N. CUEVA______________


    Signature over Printed Name of Student Signature over Printed Name of Parent/Guardian (for minor)

    Date * Time Vital Signs History * Physical Examination * Lab./s Results Diagnosis Treatment
    T:
    P:
    R:
    BP
    Wt:
    Ht:
    Snellen Reading: L-
    R-
    Ishihara Reading: L-
    R-
    CMU-F-4-HSU-003 12 Dec 2023 Rev.01

    You might also like