COMMUNITY COLLEGE OF MANITO
HEALTH SERVICE UNIT
MANITO, ALBAY
2x2 PICTURE
STUDENT ENROLMENT HEALTH RECORD PROFILE
Academic Year:___________
Please provide details of your health status. All information is confidential. (Use BLUE permanent ink. Do not use sign pen.)
o BEED
o First Term o BSED-ENGLISH
Term o Second Term Course / Program o BSED-MATH
o BSED-FILIPINO
o BSESS
Student I.D Student Category: o FIRST YEAR
No. o Old Year Level o SECOND YEAR
o New o THIRD YEAR
o Transferee o FOURTH YEAR
o Returnee
STUDENT AND FAMILY INFORMATION
Student’s Name: (Last)______________________(First)___________________(M.I.)________________
Gender: ( )Male ( ) Female Date of Birth:_________________ Age:_______Nationality:_______________
Mother’s Name:_________________________________ Contact No.:____________________________
Father’s Name: _________________________________ Contact No.:____________________________
Spouse Name (if applicable):__________________________ Contact No.:______________________
Student lives with: Both Parents ( ) Mother ( ) Father ( ) Spouse ( )
________________________________________________________________________________________________
Do not leave blanks. Write either N/A or Not Applicable; Unrecalled; or None.
PAST OR CURRENT MEDICAL CONDITIONS
Medical Condition When Identified Maintenance Medications if Any
Allergies: Food_________________Drugs:________________Environmental Agents/Factors:______________________
Hospitalizations:____________________________ Operations:_________________________
IMMUNIZATION HISTORY:
o Influenza Vaccine o Hepatitis B
o Pneumonia Vaccine o Covid-19 Vaccine: 1st Dose:______________2nd Dose:_________________
o HPV (Booster if Any):_______________________
o Hepatitis A o Other Vaccine:_____________________
FAMILY History: Among your blood relatives, is there a history of any of the following?
Name of Disease Yes No Name of Disease Yes No Name of Disease Yes No
Heart Disease Bronchial Asthma Thyroid Disease
Hypertension Allergies / Allergic Rhinitis Asthma
Tuberculosis Mental Disorder / Problem Eye Disorder
Kidney Disease Digestive Disturbances Skin Problems
Cancer Convulsions / Neurologic Others:
Problems
Diabetes Bleeding Problems/ Blood
Disorders
Personal Social History:
Smoking Drinking Alcohol
o Current _____beer per ______
o Previous _____shots per ________
o Never
Age of onset of Smoking:___________
Have you had any of the following?
Yes No Yes No Yes No
Headache (Frequent) Sore Throat Difficulty of Breathing
(Frequent)
Dizziness (Frequent) Chest Pain Frequent Urination
Fainting/ Loss of Back Pain Eczema/ Skin
Consciousness Problems
Insomia Easily Gets Tired Pregnant
If answer is YES, please give details:_____________________________________________________________________
__________________________________________________________________________________________________
I certify that the above answers and statements are true and complete, and to the best of my knowledge.
_______________________________ ______________ _______________
Student Signature Over Printed Name Year Level Date
DO NOT WRITE BELOW. TO BE ACCOMPLISHED BY THE MEDICAL PERSONNEL.
Body Mass Index (BMI): Vital Signs:
Height:____________m BP:____ /_____mmHg RR:________/minute
Weight:___________kg PR:_______/minute Temp: _______
BMI:weight(kg)
Height(mxm)
Interpretation:______________
PHYSICAL EXAMINATION: (Pertinent Findings per System)
HEENT:________________________________________________________________________________________
Chest & Lungs:__________________________________________________________________________________
CVS:__________________________________________________________________________________________
Abdomen:_____________________________________________________________________________________
Genito-urinary:_________________________________________________________________________________
Skin Extremities:_______________________________________________________________________________
Other Significant Findings:________________________________________________________________________
FITNESS CERTIFICATION:
______Fit for Enrolment _________Not Fit for Enrolment
IMPRESSION / RECOMMENDATIONS:________________________________________________________________
__________________________________________ _____________ ____________
Signature over Printed Name of Attending Physician License Number Date Examined
Note: Please issue a separate Medical Certificate using your official letterhead.
EVALUATED BY:
Name & Signature of CCM Health Services Personnel:___________________________________
Position/ Designation:____________________ Date Evaluated:____________________________
CCM-SHRF-Rev.04(08-08-23)
