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    Student Health Declaration - A4

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    carlosinon163
    For academic purposes

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    © All Rights Reserved
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    Student Health Declaration - A4

    Uploaded by

    carlosinon163
    1 views1 page
    For academic purposes

    Original Title

    STUDENT-HEALTH-DECLARATION_A4

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    © © All Rights Reserved

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    For academic purposes

    Copyright:

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    Download as docx, pdf, or txt
    1 views1 page

    Student Health Declaration - A4

    Uploaded by

    carlosinon163
    For academic purposes

    Copyright:

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

    Republic of the Philippines

    CAGAYAN STATE UNIVERSITY


    Aparri Campus
    MEDICAL-DENTAL CLINIC

    STUDENT HEALTH DECLARATION FORM

     Please fill-out the following information.


    LAST NAME:_______________________________ FIRST NAME:_____________________________
    MIDDLE NAME:_____________________ _Date of Birth:__/__/__ Age:______ Gender: M___F___
    Address:_______________________________________ Contact Number:_____________________
    Course and Year:________________________________ Major:_____________________________
     Please answer the following questions honestly. Put a check mark on the appropriate column.

    YES NO
    1. Do you consider yourself healthy and in good condition?
    2. Do you have flu-like symptoms for the past 7 days? (fever, body pain, chills and cough?
    3. Do you have difficulty breathing for the past 7 days?
    4. Do you have a close contact or exposure to any person suspected of or confirmed with
    Coronavirus Disease?
    5. Do you have an open cut/lesion/ or skin sore?
    6. Do you have or had a seizure disorder? (such as epilepsy, etc.)
    7. Do you have an immunosuppressed medical condition? (Cancer, Lupus,HIV/AIDS, Leukemia,
    Organ Transplant)
    8. Do you have Hypertension? (BP higher than 120/80mmHg)
    9. Do you have Hypotension? (BP lower than 90/60mmHg)
    10. Do you take antacids? (such as Kremil-S, Ranitidine, Omeprazole, Maalox, Aluminum-Magnesium
    Hydroxide)
    11. Do you have long-term health problem? (such as, Heart Disease, Kidney Disease, Liver Disease,
    Diabetes, Lung Disease, Asthma, Anemia. Other (please
    indicate)______________________________________________________________
    12. Do you have any history of previous hospitalization or injuries? If yes please indicate the
    reason:________________________________________________________________________
    ________________________________________________________________
    13. Are you physically challenged? If Yes Please indicate_____________________________
    14. Are you a smoker or alcohol drinker?
    15. Do you feel stressed out or under a lot of pressure lately?

    List All Known Allergies:


    _______________________________________________________________________________________________
    _______________________________________________________________________________________________

    List Any Medications You are Currently Taking:


    _______________________________________________________________________________________________
    ______________________________________________________________________________________________

    Additional Medical Information/Concerns:


    _______________________________________________________________________________________________
    _______________________________________________________________________________________________

    I HAVE been informed of the possible health risk related to my_________________. By signing this form, I
    declare that the information I have given is true, correct and complete. I understand that failure to answer
    any question or giving false answer can be penalized in accordance with law.

    _______________________________________ ___________________________________
    Signature over printed name Date

    CSU-CLINIC F-CLI-AP-
    80617

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