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Health Declaration Form

1) This document is a health declaration form that incoming students for the 2023-2024 school year must complete in lieu of a physical examination and chest x-ray. 2) It requires students to provide personal information, medical history, personal/social history, and current medications. 3) By signing, students certify that their medical history is accurate and consent to have their personal and health information collected, processed, and stored for health assessment, treatment and research purposes.

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Berlyn Colegado
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1K views3 pages

Health Declaration Form

1) This document is a health declaration form that incoming students for the 2023-2024 school year must complete in lieu of a physical examination and chest x-ray. 2) It requires students to provide personal information, medical history, personal/social history, and current medications. 3) By signing, students certify that their medical history is accurate and consent to have their personal and health information collected, processed, and stored for health assessment, treatment and research purposes.

Uploaded by

Berlyn Colegado
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
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HEALTH DECLARATION FORM

For School Year 2023-2024, in lieu of the usual Physical Examination and Chest
X- ray, incoming students are required to complete the Health Declaration 2"x2" or
Form for admission. This form will be part of your medical records as a student passport-size
and will be treated with utmost confidentiality. Please type or write in black or colored ID photo
taken within the
blue ink only. last
3 months
Allergy to:
No known allergies

Student ID No.:

Personal Information

Last Name First Name Middle Name Sex at Birth / Gender

PhilHealth ID No. __________________________ Contact Number _____________________ Email Address: _____________________

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 Joint Pain/ Arthritis
Anemia/Blood Disorder Kidney Disease
Asthma Malaria
Autoimmune Disorder Measles
Cancer Mental Problem/ Disorder
Chickenpox/ Varicella Mumps
Convulsions Neurologic Disorder
COVID-19 Pertussis (Whooping Cough)
Dengue Fever Pneumonia
Diabetes Poliomyelitis
Diptheria Rheumatic Fever
Ear Disease/ Defect Sexually Transmitted Infection
Eye Disease/ Defect Skin Disease
Fracture Surgery
Heart Disease Thyroid Disease
Hepatitis (indicate type) Tonsillitis
Hernia Tuberculosis/ Primary Complex
High Blood Pressure Typhoid
Influenza A(H1N1) Ulcer (Peptic)

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

3. For women, Are you a pregnant? YES NO

4. For women, Are you a lactating mother? YES NO

5. Are you Persons with Disability ?


[ ] Psychosocial [ ] Disability due to chronic illness [ ] Learning [ ] Visual [ ] Orthopedic [ ] Communication

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 performace as a student of the University.

I also understand that the LIFI Health Service will not be liable to any untoward incident that may
arise due to the deferral of the physical examination and Chest X-ray.

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
Note: Both student and guardian will affix their signatures, if
the former is aged below 18 years old.

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