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    (HSO) Medical Examination Form

    Uploaded by

    Krizel Lagundi
    This document is a medical examination form for a university health services office. It collects personal information like name, contact details, medical history, and results of a physical exam including vital signs, height, weight, and physical findings for various body systems. The student consents to undergoing the medical exam and having their health information kept confidential but accessible for their care and treatment. The exam results will be retained for 5 years and used to determine eligibility for enrollment in the upcoming academic year.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    (HSO) Medical Examination Form

    Uploaded by

    Krizel Lagundi
    232 views1 page
    This document is a medical examination form for a university health services office. It collects personal information like name, contact details, medical history, and results of a physical exam including vital signs, height, weight, and physical findings for various body systems. The student consents to undergoing the medical exam and having their health information kept confidential but accessible for their care and treatment. The exam results will be retained for 5 years and used to determine eligibility for enrollment in the upcoming academic year.

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    3. [HSO] Medical Examination Form

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    © © All Rights Reserved

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    This document is a medical examination form for a university health services office. It collects personal information like name, contact details, medical history, and results of a physical exam including vital signs, height, weight, and physical findings for various body systems. The student consents to undergoing the medical exam and having their health information kept confidential but accessible for their care and treatment. The exam results will be retained for 5 years and used to determine eligibility for enrollment in the upcoming academic year.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    232 views1 page

    (HSO) Medical Examination Form

    Uploaded by

    Krizel Lagundi
    This document is a medical examination form for a university health services office. It collects personal information like name, contact details, medical history, and results of a physical exam including vital signs, height, weight, and physical findings for various body systems. The student consents to undergoing the medical exam and having their health information kept confidential but accessible for their care and treatment. The exam results will be retained for 5 years and used to determine eligibility for enrollment in the upcoming academic year.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Health Services Office

    MEDICAL EXAMINATION FORM

    ENCODED BY: _____________ DATE: _________________


    (To be filled out by HSO staff) SCHOOL YEAR: __________

    ID NUMBER: _____________________ COLLEGE: _____________


    LAST NAME: _____________________ FIRST NAME: ______________________ MIDDLE NAME:_____________________
    CONTACT#: ________________
    CONTACT PERSON IN CASE OF EMERGENCY: ________________________ RELATIONSHIP: ____________________
    CONTACT#: _______________________
    AUTHORITY TO CONDUCT MEDICAL EXAMINATION
    I, __________________________, ____years old accept and understand that I am required to undergo a physical examination
    and chest x-ray to determine my fitness and well-being as a student. I fully understand that the results will be held as
    confidential medical records and will be used by the University for my care and treatment. My health information cannot be
    released to third persons except with my consent or unless the disclosure of the information is required by law. I also accept and
    understand that the procedures are requirements for the next academic year enrolment. I acknowledge that my medical records
    will be retained by the University for a period of 5 years from examination or health visit.
    ____________________
    Signature of Student

    PHEX Consultation Details


    Physical Abnormal
    Physical Exam (to be filled-out by a nurse/doctor) Findings Findings
    Medical History (updated) EENT
    Blood Type_______________ 1.__________________ _
    Blood Pressure____________ 2._______________________
    ___Normal
    Resp. Rate_______________ 3._______________________
    Head and
    Temperature______________ 4._______________________ __
    Pulse Rate________________ Neck
    Height (in inches) __________ Medications_______________ ___Normal
    Weight (in pounds) ________ __________________________ __
    BMI (to be computed by the system) _____ __________________________ Breast
    BMI Category-system-generated_______
    ___Normal
    LMP (Female) ________ Social History
    Right Vision__________ ___ Smoking
    Left Vision ___________ ___ Drinking Lungs
    ___ Exercising ___Normal
    Corrective Lens
    Findings Heart
    Extremities
    MROTC_____________ ___ Left Handed
    ___Normal
    MPE________________ ___ Right Handed
    Neurologic
    Diagnosis ___Normal
    ____________________
    ____________________ Chest X-ray
    ____________________ ___Normal
    _____________________
    Assigned Nurse Remarks/Recommendations Abdomen
    Physically Fit ___Normal
    __________________ For Clearance
    Examining Physician _________________________ Skin
    _________________________ ___Normal
    Drug test
    ____Normal
    2401 Taft Avenue, 1004 Manila, Philippines Tel: (632) 536-0252 | Trunk Line: (632) 524-4611 loc. 221

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