GAPAN CITY COLLEGE
City Hall Compound, Bayanihan, Gapan City
HEALTH DECLARATION FORM
2”x2” or passport-size
colored ID photo
For the upcoming GCC’s 6th Founding Anniversary students are required to taken within the last
complete the Health Declaration Form for them to be able to join the 3 months
Palarong GCC 2024. This form will serve as your medical records as a student
and will be treated with utmost confidentiality.
Student No. 20230160
Personal Information
Dimapasok Castillo Rencelle
Last Name First Name Middle Name Gender :
Female
Date of Birth: 2004/12/23 Birthplace: Purok 5 Sto. Cristo San Antonio Nueva Ecija
Age: 19
(yyyy/mm/dd)
Contact No.: 09668564499 Email Address: dimapasokrencelle@gmail.com
Home Address: Purok 5 Sto. Cristo San Antonio Nueva Ecija
Medical History
Have you ever had or do you have any of the following? Check EACH item YES or NO. If yes, give details.
YES NO DETAILS YES NO DETAILS
Accident/ Injuiries Fracture
Anemia/Blood Disorder Heart Disease
Asthma Hernia
Autoimmune Disorder High Blood Pressure
Cancer Hepatitis (indicate type)
Kidney Disease Eye Disease/ Defect
Joint Pain/ Arthritis Poliomyelitis
Measles Typhoid
Mental Problem/ Tuberculosis/ Primary
Disorder Complex
OSAS Health Declaration Form s.2024 Page 1 of 3
Mumps Tonsillitis
Neurologic Disorder Thyroid Disease
Pertussis (Whooping Sexually Transmitted
Cough) Infection
Chickenpox/ Varicella Pneumonia
Details Details Convulsions
Malaria COVID-19
No known allergies Dengue Fever
Ulcer (Peptic) Diabetes
Skin Disease Diptheria
Surgery Ear Disease/ Defect
Influenza A(H1N1) Rheumatic Fever
Personal/ Social History
Encircle your answer to the following questions:
1. Do you smoke cigarettes/ tobacco products? YES NO
2. Do you drink alcoholic beverages? YES NO
Answer the following questions briefly.
Describe any other important health-related information about you.
(for example: hospitalizations, health concerns requiring special treatment/ diet, etc.)
List all prescriptions and over-the-counter medications you are currently taking.
Do you have any immediate health concerns that you think may affect your studies? Please specify.
DECLARATION AND DATA SUBJECT CONSENT FORM
I certify that the above history is true to the best of my knowledge. I have fully disclosed all medical conditions that may affect my
performance as a participant of the event aforementioned.
I also understand that the Gapan City College will not be liable to any untoward incident that may arise during the event.
OSAS Health Declaration Form s.2024 Page 2 of 3
In compliance with the Data Privacy Act of 2012 and its Implementing Rules and Regulations, I voluntarily consent to the collection,
processing, and storage of my personal and health information for the purpose/s of health assessment, treatment, and/ or research
(following research ethics guidelines) for the improvement of healthcare services.
Name and Signature of Student
Please submit the accomplished form to your respective coordinators.
OSAS Health Declaration Form s.2024 Page 3 of 3
