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Health Assessment Form

This document is a health assessment form for a student containing personal information like name, address, contact details, as well as medical history and current health conditions. It collects information on illnesses, allergies, medications, immunizations and other treatments. Physical and mental health are assessed through a review of symptoms. The form allows sharing health information with physicians and provides space for a health personnel's notes on treatment and fitness for school.

Uploaded by

Meljoy Tenorio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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162 views5 pages

Health Assessment Form

This document is a health assessment form for a student containing personal information like name, address, contact details, as well as medical history and current health conditions. It collects information on illnesses, allergies, medications, immunizations and other treatments. Physical and mental health are assessed through a review of symptoms. The form allows sharing health information with physicians and provides space for a health personnel's notes on treatment and fitness for school.

Uploaded by

Meljoy Tenorio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Republic of the Philippines

DEPARTMENT OF EDUCATION
Region 02 – Cagayan Valley
SCHOOLS DIVISION OF THE CITY OF ILAGAN

Health Assessment Form


Name ______________________________________________________________________________
Address ______________________________________________________________________________
Guardian/ Contact phone numbers __________________________________________________________
Birth date ______________________________________________________________________________

Family Physician and/or Primary Health Care Provider:


Doctor/Other__________________________________ Phone __________________________________
Address _____________________________________ City _____________________________________

May I send a copy of your consultation to your physician or primary health care provider and consult with them as
necessary?
 Yes  No
Signature:

Marital Status: Sex:

Occupation:
Position _____________________________________ Employer ________________________________
Address ______________________________________________________________________________
Phone ______________________________________________________________________________

Chief Complaint:
Subjective:

Objective:
Present Medical History

Check those questions to which you answer yes (leave the others blank).
 ASTHMA
 DIABETES
 HYPERTENSION
 KIDNEY/LIVER PROBLEMS
 HEART DISEASE
 EAR INFECTION
 RECURRENT SORE THROAT
 ALLERGIES

Comments: ___________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Do you now have or have you recently experienced:


REVIEW OF SYSTEMS:
Integumentary [ ] pruritus [ ] lesions [ ]fever

Head and Neck


[ ] headache) [ ] syncope [ ] dizziness
[ ]blurring of vision [ ]diplopia [ ]conjunctivitis/red eyes
[ ]photophobia [ ]eye pain [ ] hearing loss
[ ]ear pain [ ]discharge [ ] tinnitus
[ ] vertigo [ ] sense of smell [ ] colds
[ ]nasal obstruction [ ] epistaxis
[ ]hoarseness [ ] sore throat
[ ] disturbance of taste

Respiratory
[ ] dyspnea [ ] orthopnea
[ ] difficulty of breathing

Cardiovascular
[ ] palpitation [ ] orthopnea
[ ] shortness of breath [ ] chest pain
Gastrointestinal
[ ] poor appetite [ ] dysphagia
[ ] constipation [ ] flatulence
[ ]abdominal enlargement [ ] LBM
[ ] steatorrhea [ ] hematochezia
[] hematemesis

Genito-urinary
[ ] dribbling [ ] incontinence
[ ] hematuria [ ] polyuria
[ ] oliguria [ ] passage of stone
[ ] discharge

Musculoskeletal
[ ] swelling
[ ] joint pain and stiffness
[ ] bone deformity [ ] atrophy
[ ] restriction of motion

Neuropsychiatric
[ ] syncope [ ] seizures [] weakness
[ ]headache [ ] tremors
[ ] loss of memory [ ] depression
[ ] delirium [ ] hallucination

Endocrine
[ ] heat or cold intolerance
[ ] polyuria [ ] polydypsia
[ ] polyphagia
[ ] abnormal growth

Hematologic

[ ] easy bruisability [ ] pallor

Comments: ___________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Women only answer the following. Do you have?


 Menstrual period problems?
 Significant childbirth - related problems?
 Urine loss when you cough, sneeze or laugh?
Date of the last pelvic exam and / or Pap smear ______________________________________________________

Comments: ___________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Men and women answer the following:

Recent travel and/ or exposure: __________________________________________________________________

List any prescription medications you are now taking: __________________________________________________


_____________________________________________________________________________________________
_____________________________________________________________________________________________

List any self-prescribed medications, dietary supplements, or vitamins you are now taking:____________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

List hospitalizations, including dates of and reasons for hospitalization:____________________________________


_____________________________________________________________________________________________
List any drug allergies:___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

List of routine immunization:

Vaccination Date Date Date Date

List of Household members and if symptomatic at time of examination:

Vaccination Date Symptoms if Remarks


present
TREATMENT/MEDICATION:

Medicine Dosage Frequency Time Signature

 PHYSICAL AND MENTALLY FIT


 REFERRAL TO BHERT/ CHO for SYMPTOMS

______________________________

Name of Health Personnel

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