UPHS FORM NO.
2
Revised 2/1/2018
UNIVERSITY OF THE PHILIPPINES U.P. Student No. _______________
HEALTH SERVICE
College:______________________
ENTRANCE HEALTH EXAMINATIONS
A complete Medical History and Physical Examination is compulsory to complete your admission to the University of the Philippines and must be on file on or before
your registration. This is the responsibility of the applicant and not your physician. Please type or complete in Ink. This record will be treated with confidentiality.
Important: Please bring accomplished form with you to the U.P. Health Service when you come for physical examination
PLEASE KEEP THIS FORM NEAT AND CLEAN
A. Complete this form if you are enrolling during a regular semester and if you are:
1 A beginning undergraduate or a beginning graduate student
2 A transfer student from a regional campus or another school or university
3 A re-entry student (undergraduate or graduate) who has been out of the University of the Philippines for at
least one semester 2x2 or passport-size
4 A graduate student employed under the classification of "Graduate Assistant" or "Graduate Instructor" ID photo
taken within
B. Completion of this form is not required if: the last
3 months
1 You are a foreign student sponsored by a government agency whose files provide a complete health record
signed by a physician. A copy of the health record should be submitted in lieu of this form.
2 A U.P. student enrolling for a Summer Session only.
Allergic to: Entrance Date to U.P.
No known allergies
Please print
Last Name First Name Middle Sex Age
Single Married Widowed Divorced
Date of Birth: Place :
College/ School of Registration in the University of the Philippines : ________________________________________________________________________________
Freshman Sophomore Junior Senior Graduate Special
Home Address : Contact No.
No Street City Province Country
Address while in School: Contact No.
Name of Parent/Guardian/Spouse:
Address: Contact No.
Family History
Mother Living If deceased, Cause of death
(Age) (Age at death)
Father Living If deceased, Cause of death
(Age) (Age at death)
Among your blood relatives, is there a history of any of the following:
Yes No Relationship Yes No Relationship
Cancer Diabetes
Heart Disease Mental Disorder/Problem
High Blood Pressure Asthma or Hay Fever
Stroke Convulsions/Neurologic Problems
Tuberculosis Bleeding Problems/Blood Disorders
Kidney Disease Digestive disturbances
Arthritis/Rheumatism Skin Disease
Personal History. Give the appropriate age to which you had the following:
AGE AGE AGE
Anemia/Blood Disorder Hernia Poliomyelitis
Asthma High Blood Pressure Rheumatic Fever
Cancer Influenza A (H1N1) (indicate date) Skin Disease
Chickenpox Joint Pains/Arthritis Smallpox
Convulsions Kidney disease Syphillis
Dengue Malaria Thyroid Disease
Diabetes Measles Tonsilitis
Diphtheria Mental Problem/Disorder Tuberculosis/Primary Complex
Ear disease/defect Mumps Typhoid
Eye disease/defect Neurologic Problem/Disorder Ulcer (peptic)
Gonorrhea Pertussis (Whooping cough) Ulcer (skin)
Heart disease Pleurlsy Other conditions (please list)
Hepatitis (indicate type) Pneumonia
Have you ever had or do you have any of the folowing. Check each item Yes or No.
YES NO YES NO YES NO
Headaches (frequent) Sore throat (frequent) Diarrhea/Constipation (specify)
Dizziness (frequent) Chest pain Joint pains
Fainting/Loss of consciousness Back pain Muscle pain (frequent)
Insomnia Easily gets tired Frequent urination
Depressed mood (> 2 weeks) Difficulty of breathing Eczema/Skin problems
Eye/Visual problems Palpitations Fracture
Hearing problems Swelling of feet Accident/Injuries
Cough (> 2 weeks) Nausea (frequent) Hospitalization (reason)
Colds/Nasal Congestion Vomiting Operation (specify)
Fever (frequent/recurrent) Abdominal pain/discomfort Others, specify
Frequent early morning sneezing Loss of appetite
Nosebleed (frequent) Weight loss/gain (specify)
If answer is Yes, give details
Do you worry too much? ___________ Does your self-consciousness interfere with your getting along with others easily? _______________________________
Are you bothered by a feeling that people are watching you or talking about you? ________________ Are you concerned about alternating period of gloom and
cheerfulness? _______________ Is it difficult for you to pull out of a depressed mood? ___________
Are you inclined to be secretive or seclusive? _______________________________________________________________________________________
Date of last dental check up ______________________________________ Date of last eye refraction _________________________________________________
Do you consider yourself in good health? Yes ____ No ____ If not, give details__________________________________________________________________
Do you wish to discuss any question with regards to your health, family history, sex or personal habit with a physician. Yes _____ No _______ Are you taking any
medicines regularly? Yes ____ No ____ If so, what are these medicines?___________________________________________________________________
Do you have any physical condition or handicap which requires special treatment, diet or other special consideration? Yes ______ No _______
FOR FEMALE STUDENTS:
Menstruation: Have not begun __________ or Age at onset __________ Periods occur every ____ to ____ days
Duration ____ days Flow: ____ Moderate ____ Excessive ____ Scanty Painful: _______ Incapacitating: ____________
Bleeding between periods: Yes _____ No _____
Have you had any trouble with your breasts, such as lumps, tumor, surgery? No ____ Yes _____. If so, give details ___________________________________
_______________________________________________________________________________________________________________________________________
I certify that the above history is true to the best of my knowledge.
Signature and Date
UPHS FORM NO. 2-C
Revised 2/1/2018
Print
Name __________________________________________________________________________________________ Age : ________ Sex : ___________ Civil Status : ____________
(Last) (First) (Middle)
(Do not write below this line. To be filled out by the physician)
Vital signs and anthropometric measurements:
Pulse rate: ______beats/min. Blood Pressure: _________mmHg Respiratory Rate: ________breaths/min. Temperature: _________
Height : ____________ cm. Weight : ____________ kg. Body Mass Index : _________ Asia-Pacific BMI Cut-Offs
[wt. in kg./(ht. in m.)^2]
Underweight
General Health Appearance : Excellent, good, fair, poor. ___ Severe Thinness <16.00
___ Moderate Thinness 16.00-16.99
___ Mild Thinness 17.00-18.49
Visual Acuity: Without Glasses With Glasses/Contact Lens
FAR NEAR FAR NEAR ___ Normal 18.50-22.99
___ Overweight 23.00-24.90
Right: ______________ : _____________ ______________ : _____________
Obese
Left: ______________ : _____________ ______________ : _____________ ___ Obese 1 25.00-29.90
___ Obese 2 >30.00
Color vision : _____________________________________
Please check apporpriate box whether findings are normal or abnormal for each organ/system; if with abnormal findings, please describe findings below
Organs/Systems: Normal Abnormal If abnormal, please describe findings
Skin
Head/Scalp
Eyes
Ears
Nose
Mouth/Oropharynx
Neck
Heart
Lungs
Back/Spine
Abdomen
Extremities
Genito-urinary/Ano-reactal
Neurologic
Chest x-ray findings: _________________________________________________________
Activity: I Unlimited II Unlimited with observation III Resticted and corrective IV Reconstructive V No Activity
ASSESSMENT RECOMMENDATIONS
Examined by: ___________________________________________
PRC license number: ____________________________________
Date examined: _________________________________________
