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Med Info Sheet

This document contains the student medical information sheet for Nicole Anne Deocaris, a 3rd year law student at Arellano University School of Law. Some key details include that she is 26 years old, single, and from Caloocan City. Her emergency contact is her mother. Her medical history notes that she had common childhood illnesses and has received the Sinovac and AstraZeneca COVID-19 vaccines. She occasionally drinks liquor and coffee 1-2 times per week. Her family history indicates hypertension and heart ailment.

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58 views1 page

Med Info Sheet

This document contains the student medical information sheet for Nicole Anne Deocaris, a 3rd year law student at Arellano University School of Law. Some key details include that she is 26 years old, single, and from Caloocan City. Her emergency contact is her mother. Her medical history notes that she had common childhood illnesses and has received the Sinovac and AstraZeneca COVID-19 vaccines. She occasionally drinks liquor and coffee 1-2 times per week. Her family history indicates hypertension and heart ailment.

Uploaded by

nicole5anne5dddddd
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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ARELLANO UNIVERSITY

SCHOOL OF LAW
MEDICAL & DENTAL CLINIC
Taft Avenue Corner Menlo Street Pasay City
1x1 pic
84043089 to 93 loc 24
auslclinic@arellanolaw.edu
STUDENT MEDICAL INFORMATION SHEET
PERSONAL DATA:

DEOCARIS NICOLE ANNE CORPUZ


STUDENT’S NAME: SURNAME GIVEN NAME MIDDLE NAME

STUDENT No. 2 0 2 3 - 0 5 7 2 FRESHMEN: TRANSFEREE: x0 REFRESHER:


YR. LEVEL: 1ST 2ND x 3RD 4TH
BIRTHDAY: AUG. 7 1997 PLACE OF BIRTH: MANILA AGE: 26
CIVIL STATUS: SINGLE SEX: FEMALE RELIGION:CATHOLIC
BLOOD TYPE: B+ WEIGHT: 70 KG HEIGHT: 157 cm BMI:
CITY ADDRESS: BAGUMBONG, CALOOCAN CITY
PROVINCIAL ADDRESS: N/A
CONTACT NUMBER: 09567048719 EMAIL ADDRESS: deocarisn@gmail.com
EMERGENCY CONTACT: DINALYN DEOCARIS RELATIONSHIP: MOTHER
CONTACT NUMBER: 09195033824 ADDRESS: BAGUMBONG, CALOOCAN CITY
MEDICAL HISTORY:
Have you had any common childhood illness Chicken pox X Measles X German Measles X Mumps X
Have you ever been hospitalized? No X Yes Why: ____________________________
Have you had any serious injuries and/or broken bones? No X Yes if yes, describe: ______________________
Have you ever received a blood transfusion? Not sure No X Yes When: __________________
Have you been infected with COVID- 19? No X Yes When: _____________________________
Have you received the Covid-19 Vaccine? SINOVAC
No X Yes Primary: ___________________________
ASTRAZENECA
1st Booster Shoot: _________ 2nd Booster Shot: _________
PRESENT ILLNESS:
Indicate whether you had a medical problem and/or surgery
N/A
_____________________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________________________________________
MEDICATIONS:
Are you currently taking any prescription and/or non-prescription medications X No Yes, Pls. Indicate
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
___________________________________________________________________________________________________________
N/A
ALLERGY: FOOD: _______________________________________________________________
N/A
MEDICINES: ___________________________________________________________
N/A
OTHERS: ______________________________________________________________
FAMILY HISTORY:
x HYPERTENSION DIABETES KIDNEY PROBLEM EENT
x HEART AILMENT ASTHMA SKIN DISEASE OTHERS: _____________
SOCIAL HISTORY:
SMOKING FREQUENCY: ________________________
x DRINKING
x LIQUOR CASUALLY
FREQUENCY: ________________________
x COFFEE 1-2 TIMES A WEEK
FREQUENCY: ________________________

I hereby attest to the truth of the foregoing medical information.


NICOLE ANNE DEOCARIS
________________________________
10-19-2023
___________
Signature over Printed Name Date

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