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Student Health Profile

The document is a student health profile form from Governor Mariano E. Villafuerte Community College in Libmanan, Camarines Sur, Philippines. It collects information about a student's personal details, medical history, vaccinations, and available health records. The two-page form gathers data on the student's name, ID number, program of study, demographic info, family contacts, past and current health conditions, surgeries, lifestyle habits, and COVID vaccination history. It also includes a health record section to document any visits to the school nurse, listing the date, complaints, physical exam findings, and management. The profile aims to have current health information on file for each student.

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Joshua Torzar
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107 views5 pages

Student Health Profile

The document is a student health profile form from Governor Mariano E. Villafuerte Community College in Libmanan, Camarines Sur, Philippines. It collects information about a student's personal details, medical history, vaccinations, and available health records. The two-page form gathers data on the student's name, ID number, program of study, demographic info, family contacts, past and current health conditions, surgeries, lifestyle habits, and COVID vaccination history. It also includes a health record section to document any visits to the school nurse, listing the date, complaints, physical exam findings, and management. The profile aims to have current health information on file for each student.

Uploaded by

Joshua Torzar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Republic of the Philippines

GOVERNOR MARIANO E. VILLAFUERTE COMMUNITY COLLEGE – LIBMANAN


Potot, Libmanan Camarines Sur
gmvcc.lib16@gmail.com

STUDENT HEALTH PROFILE

INFORMATION

Name: ________________________________________________________

Student ID Number: ___________________

Course and Year/Section: _________________________________________

Gender: ________ Date of Birth: _____________ Place of Birth: ___________________ Age: _________

Civil Status: __________________ Religion: _____________________ Mobile: _____________________

Home Address: ________________________________________________________________________

Father’s Name: _____________________________________________ Mobile: ____________________

Mother’ s Name: ____________________________________________ Mobile: ___________________

With whom does the student live? ___ Father ___ Mother ___ Both ___ Spouse ___Guardian

Guardian’s Name: ____________________________________________ Relation: __________________

Spouse Name: _______________________________________________ No. of Children: ____________

PAST MEDICAL HISTORY

Please check Y (yes) and N (no) for each condition.


Y N Y N Y N Y N
Allergies * Bronchitis Seizures Low Blood Pressure
Chills Joint Problems Back Pain Fever
Sinusitis Hemorrhoids Ear Infections Kidney Stones
Paralysis Dizziness Heart Disease * Excessive Fatigue
Anemia Chest Pain Tremors Chronic Swelling
Diabetes * Cancer * Vomiting Shortness of breath
Thyroid Convulsions Epilepsy Sexually Transmitted Disease *
Anxiety Meningitis Chronic Cough Urinary Tract Infections
Eczema Depression Chronic Colds Tuberculosis *
Arthritis Constipation Pneumonia Diarrhea
Nausea Fainting Malaria Hernia
Insomnia Nervous panic Appendectomy Heartburn
Asthma Head Injury High Blood Pressure Ulcers *
Hepatitis * Sickle Cell

Other health condition: _________________________________________________________________

Specify ( * ) :__________________________________________________________________________

PAST SURGICAL HISTORY (If Applicable)

Operation: ____________________________________________________ Date: __________________


PERSONAL / SOCIAL HISTORY

Smoking: ___Yes ___No ___Quit Year Started: _______ No. of pack (Months) _______________

Alcohol: ___Yes ___No ___Quit Year Started: _______ No. of bottles (day/month) __________

Illicit Drugs: ___Yes ___No ___Quit Year Started: _______ Type of Drugs: ____________________

GYNECOLOGIC/UROLOGIC HISTORY (if applicable)

FEMALE

Age at Menarche: ______________________

Last Menstrual Period: ______________________________

Menstrual Pattern (Cycle/Duration): _____________________________

Onset of sexual intercourse: ____________________________________

Pregnancy History: (GPFPA)___________________________________________________________

Gynecologic complaints and infection history: ____________________________________________

MALE

Age of Circumcision: __________________________

Urologic complaints and infection history: _______________________________________________

Person with disability: Yes or No_________________________________________ ID no. ___________


(Please mention or specify the condition/disability)

COVID VACCINE HISTORY

1st Dose: Date given: _________________ Vaccine Name: ____________________

2nd Dose: Date given: _________________ Vaccine Name: ____________________

Booster: Date given: _________________ Vaccine Name: ____________________

Health Facility Name: ___________________________________________________________________

AVAILABLE MEDICAL DOCUMENTS

Medical Certificate: _____________________________________________________________________

Medical Laboratories: ___________________________________________________________________

_______________________ ______________
Student Signature Date

AQUILINO C. DEBORDE, BSN-RN, LPT


School Nurse
Republic of the Philippines
GOVERNOR MARIANO E. VILLAFUERTE COMMUNITY COLLEGE – LIBMANAN
Potot, Libmanan Camarines Sur
gmvcc.lib16@gmail.com

HEALTH RECORD

NAME: _______________________________________________________
DATE COMPLAINTS PHYSICAL EXAM MANAGEMENT
DATE COMPLAINTS PHYSICAL EXAM MANAGEMENT
Republic of the Philippines
GOVERNOR MARIANO E. VILLAFUERTE COMMUNITY COLLEGE – LIBMANAN
Potot, Libmanan Camarines Sur
gmvcc.lib16@gmail.com

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