UP FORM NO.

2
UNIVERSITY OF THE PHILIPPINES BAGUIO
HEALTH SERVICE

ENTRANCE HEALTH EXAMINATION

A complete Medical History and Physical Examination is compulsory to complete your admission to the University of the Philippines
and must be on File for registration. This is the Responsibility of the Applicant and not your Physician. Please type or complete in ink.
This Record will be treated confidentially.

Important: Please bring accomplished form with you to the UP Health Service when you come for your physical examination.
PLEASE KEEP THIS FORM NEAT AND CLEAN

A. Complete this form if you are enrolling during a regular semester and you are:
1. A beginning undergraduate or a beginning graduate student.
2. A transfer student from a regional campus or another school.
3. A re-entry student (undegraduate or graduate) who has been out of the University of the Philippines for at least one
semester.
B. Complete this form when enrolling during a regular semester if you are:
1. A graduate student employed under the classification of “Graduate Assistant” or
“Graduate Instructor”.
C. Do not complete this form if:
1. You are a foreign student sponsored by a government agency whose file provides a
complete health record signed by a physician. A copy of that health record should be
submitted in lieu of this form.
2. Enrolling for a Summer Session only.
__________________________________________________________________________________________________________

Date ____________________
PLEASE PRINT

Last Name First Name Middle

__________ ____________________________________ Age _______ Gender______

Civil Status Religion

Date of Birth ________________________ Place _____________________________________________

College/School of Registration in the University of the Philippines ________________________________

Freshman / / Sophomore / / Junior / / Senior / / Graduate / / Special / /

Home Address ____________________________________________________________________________________________

No Street/Barangay City/Town Province

Address while at school ___________________________________________________________ Tel. No. _____________

Name of Parent/guardian/spouse___________________________________________________________

Address: ____________________________________________________________________________ Tel. No. _____________

FAMILY HISTORY:

Mother: Living _____; Dead __________; Cause of Death ___________________________________

(age) (age at death)

Father: Living _____; Dead __________; Cause of Death ____________________________________

(age) (age at death)

Has any member of your immediate family attended the University of the Philippines? Yes / / No / / Relation ______________

Among your blood relatives, is there history of any of the following?

YES RELATIONSHIP YES RELATIONSHIP

Cancer Skin diseases
Heart disease Diabetes
High Blood Pressure Nervous or Mental diseases
Stroke Asthma or Hay fever
Tuberculosis Convulsions
Kidney trouble Tendency to bleed easily
Rheumatism Digestive disturbances
PERSONAL HISTORY: Give approximate age when you had the following:
Age Age Age
Anemia High blood pressure Rheumatic fever
Chicken Pox Influenza Skin disease
Convulsion Joint pains Small pox
Diabetes Kidney disease Syphilis
Diphtheria Malaria Thyroid trouble/Goiter
Ear disease/defect Measles Tonsillitis
Eye disease/defect Mumps Tuberculosis
Gonorrhea Nervous or mental disorder Typhoid fever
Heart disease Pleurisy Ulcer (peptic)
Hepatitis Pneumonia Ulcer (skin)
Hernia Whooping cough Meningococcemia
Other conditions (Pls. Indicate) Dengue Fever/Dengue Hemorrhagic fever

Have you ever had or do you now have any of the following?
Yes Yes Yes
Asthma Fainting Nosebleeding
Backaches Hay fever Rapid pulse
Chest pain Headaches Sore throat
Cough Indigestion Swollen feet
Depression Influenza Frequent urination
Diarrhea (frequent) Insomia Vomiting
Difficulty of breathing Joint pains Others (Pls. specify)
Dizziness Loss of weight
Eczema Nausea (frequent)

If answer is YES, give details: _____________________________________________________________

Medical and surgical history, serious illness, operation, fracture, injuries and accident. Please give details.

If your tonsils have been removed, indicate condition of health since operation: IMPROVED, SAME, WORSE.

Are you allergic to any food, serum, drug or medicine (Penicillin, antitoxin, etc)? YES _____ NO ______
If so, list ______________________________________________________________________________

Are you taking any medicine regularly? YES ____ NO _____ If so, what ___________________________

Do you have any physical condition or handicap that requires special treatment, diet or other special consideration? YES ___ NO ___.
If YES, give details _________________________________________

Date of last dental check-up: _______________ Date of last eye refraction:_________________________

Do you worry too much? ____Does your self-consciousness interfere with your getting along easily? ___
Are you bothered by a feeling that people are watching you or talking about you? ___ Are you concerned about alternating periods of
gloom and cheerfulness? ___ Is it difficult to pull out of a depressed mood? ___ Are you inclined to be secretive and seclusive? ___.

Do you consider yourself in good health? YES ___ NO ___. If NOT, what are your complaints _________

FEMALE STUDENTS ANSWER THE FOLLOWING: Menstruation: Has not begun ___ or Age at onset ___ Interval: Occurs every
___to ___days. Duration: ___days. Flow: ___Excessive ___Moderate ___Scanty ___Painful ___ Incapacitating. Bleeding between
periods: Yes ___No ___. Have you had any trouble with the breasts? Lumps, tumor, surgery, etc. Yes ___No ___ If so, explain
___________________

MALE STUDENTS ANSWER IN FULL: Have you now or have you had any hernia or rupture? Yes ___ No ___. Have you had any
trouble with your testicles (infection, injury, surgey)? Yes ___No ___. If so, explain
_______________________________________________________________________________

I CERTIFY THAT THE ABOVE HISTORY IS TRUE TO THE BEST OF MY KNOWLEDGE.

____________________________________
Signature