CITY GOVERNMENT OF LIGAO
LIGAO COMMUNITY COLLEGE 2x2 picture with
Tomolin, Ligao City, 4504 nametag
LiComCoClinic_Form No.01 Email – Address: ligaocommunitycollege@gmail.com
Rev: 04_2024 Tel Nos.: 0926 – 772 - 1213 / (052) 431-4124
STUDENT’S MEDICAL INFORMATION
A.Y. 2024-2025
NAME Last Name: First Name: Middle Name
ADDRESS PWD: ___YES TYPE OF DISABILITY:
SEX AGE ___NO __________________________
YEAR/BLOCK COURSE/MAJOR PWD ID NO :
BIRTHDAY STATUS CITIZENSHIP
REGISTERED
If yes, write your PHILHEALTH NUMBER___________________________
TO _______ YES _______ NO
(indicate the PHILHEALTH NUMBER of parents if beneficiary of parents)
PHILHEALTH
In case of emergency, person to contact:
NAME RELATIONSHIP ADDRESS CP #
Please put a check mark on the appropriate column/box below.
MEDICAL HISTORY: Present and past illness.
A YES NO B YES NO
Eye Disease Hypertension (High Blood)
Ear Infection Hypotension (Low Blood)
Hearing Defect Anemia (Low Blood Count)
Sinusitis Heart Disease (Sakit sa Puso)
Nose Bleeding Diabetes
Frequent cough/cold Ulcer
Tonsillitis/Pharyngitis Hyperacidity
Neck Mass/ Goiter Kidney Disease/ UTI
Asthma Skin Disease
Tuberculosis Allergies
Bronchitis Loss of Consciousness (Hinimatay)
Pneumonia Frequent Headache/Migraine
C YES NO D YES NO
Dizziness/Vertigo Chest Pain
Depression Breast Cyst/Mass
Epilepsy/Convulsion Abdominal Mass
Weakness/Paralysis Hernia (Luslos)
Arthritis Genital Abnormality/Deformity
Fracture (Bali) Spine Injury/Deformity
Measles (Tigdas) Thigh Injury/Deformity
Chicken Pox (Bulutong) Hemorrhoids (Almoranas)
Mumps (Beke) Past/Present Medication(s)
Hepatitis Previous Accident(s)
Malaria Previous Hospitalization(s)
Sexually Transmitted Disease (STD) Previous Operation(s)
REMARKS:
FAMILY HEALTH HISTORY
(pls. list pertinent illness/diseases)
MOTHER
FATHER
SISTER(S)/BROTHER(S)
GRANDPARENTS
OB-GYNE HISTORY: For female students only
LAST MENSTRUAL PERIOD
MENSTRUAL PATTERN: PREGNANT NOW? MYOMA (first day of menstruation)
____ Monthly ___ Yes ___ Yes
____Irregular ___ No ___ No ___________________
DYSMENORRHEA: NUMBER OF MISCARRIAGES
OVARIAN CYST:
NUMBER OF PREGNANCIES : ___ No (ilang beses na nakunan)
___ Yes
__________ ___ MODERATE
___ No
___ SEVERE __________
Others: Remarks:
SOCIAL HISTORY (please specify year below)
A. SMOKING ___ YES ___ NO
If Yes, since _______________, # of sticks per day ________
B. DRINKING ALCOHOLIC BEVERAGES ___ YES ___ NO
If Yes, since _______________, # of bottles ____________; Daily ___ Weekly ___ Occasional ___
REMARKS:
Please list any drugs, medicines, birth control pills, vitamins and minerals (prescribed and non-prescribed) you use and
indicate how often you use it.
NAME OF MEDICINE USE DOSAGE
PREFERRED HOSPITAL IN CASE OF EMERGENCY
CERTIFICATION AND CONSENT
I certify that the answers and statements above are all true and correct to the best of my knowledge.
_____________________________ ___________________________
STUDENTS NAME DATE ACCOMPLISHED
*** Attach photocopy of medical certificate or other important papers if with present medical condition.
