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De La Salle UniversityM E D I C A L A N D D E N TA L S E R V I C E S

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MANILA

FORM B

NAME:

Age: Date of Birth: Gender:

Address: Contact No.:

Instructions for Physician: Fill out all sections of this form. To record data from patient’s Physical Examination, please tick appropriate boxes and fill-up the necessary information.

Review of Systems:

headache dyspnea hyperacidity weakness migraine tachypnea dysmenorrhea deficit dizziness cough loss of appetite hallucination hemoptysis blurring of vision hematochezia syncope visual loss chest pain melena convulsion palpitations hematemesis depression hearing impairment easily fatigued dysuria nose bleeding difficulty of breathing frequency fever tinnitus chills colds abdominal pain neck pain malaise constipation back pain jaundice diarrhea muscle pain others vomiting joint pain

Physical Examination

Blood Pressure Height (in inches)Pulse Rate Weight (in pounds)Resp. Rate Blood Type (please bring official result)

Temperature LMP

Eye Examination Right Left

Visual Acuity (using Snellen Chart)

Yes No Contact LensGlassesColor Blind

Family Name First Name Middle Name

Head and Neck

EENT

Chest / Lungs

Breast

Chest X ray results (must have been taken within the last six (6) months)Date

Normal Abnormal findings Normal Abnormal findingsHeart

Abdomen

Skin

Extremities Left-handed Right-handed

In view of the student’s history and physical examination, is it your assessment that his / her health status is adequate for studies / school activities, without restrictions? Yes No

If with restrictions, what are your recommendations?Other remarks:

Diagnosis:

Date:

Physician’s Name and Signature:License Number: Contact Number:

Clinic Address:

Reminder: This form must be submitted to the University Clinic together with the official chest x-ray, blood type, and drug test results.

Note: Do not PHOTOCOPY this form. It should be downloaded and printed directly from the online freshman consultation page.

HEALTH SERVICES OFFICEID Number: __________________

Contact Person (in case of Emergency): ____________________________________________ Contact No.: __________________

Review of Systems:

Past Medical History ____________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

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Pertinent Review of Systems (attach additional sheet if necessary) ________________________________________________

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