00 Template Uhs Patient Record 1

WESTERN MINDANAO STATE UNIVERSITY
ZAMBOANGA CITY
UNIVERSITY HEALTH SERVICES CENTER
Tel. no. (062) 991-6736 / Email: healthservices@wmsu.edu.ph
PATIENT HEALTH PROFILE & CONSULTATIONS RECORD

(Electronic or Paper-based Input)
Name:
(Photo of Patient)
Barcelona Aldrin James Gardose
(Surname) (First name) (Middle name)
Age: 18 Sex: Male Course: BS in Electrical Engineering

Year Level: 1st
Birthday (MM-DD-YY): 07-20-2005 Religion: Roman Catholic
Nationality: Filipino Civil Status: Single
Email Address: barcelonaaj20@gmail.com Contact #: 09919670468
City Address:
Zamboanga City
Provincial Address (if applicable):
Emergency Name: Erlinda G. Barcelona

Contact Person
within Contact #: 09922835982 Relationship: Mother
Zamboanga
City City Address:
Zamboanga City
Which of these conditions do you currently have?

Bronchial Asthma ("Hika")
Food Allergies (Specify food:___________________________)
Allergic Rhinitis
Hyperthyroidism
Hypothyroidism/Goiter
Comorbid Anemia
Illnesses Psychiatric Illness:
Major Depressive Disorder
Bipolar Disorder
Generalized Anxiety Disorder
WMSU- UHSC-FR-001-01
Effective Date: 30-May-2023
Panic Disorder
Posttraumatic Stress Disorder
Schizophrenia
Other: ____________________________________
Migraine (recurrent headaches)

Epilepsy/Seizures
Gastroesophageal Reflux Disease (GERD)
Irritable Bowel Syndrome
Hypertension (elevated blood pressure)
Diabetes mellitus (elevated blood sugar)
Dyslipidemia (elevated cholesterol levels)
Arthritis (joint pains)
Systemic Lupus Erythematosus (SLE)
Polycystic Ovarian Syndrome (PCOS)
Cancer (Specify:________________________)
Other: _____________________________________________________
Generic Name of Drug Dose and Frequency

1.
2
.
Maintenance
Medications 3
.
4
.
5.
Fully vaccinated (Primary series with or without booster shot/s)

COVID-19
Vaccination Partially vaccinated (Incomplete primary series)
Not vaccinated
Age when menstruation began: ________ Menstrual Symptoms:

Regular (monthly) Dysmenorrhea (cramps)
Menstrual & Irregular Migraine
Obstetric History Loss of consciousness
(for females only) Number of pregnancies: ______
Number of live children:______ Other:_______________________
Which of these conditions have you had in the past?
Varicella (Chicken Pox) Measles

Dengue Typhoid fever
Tuberculosis Amoebiasis
Pneumonia Nephro/Urolithiasis
Urinary Tract Infection (kidney stones)
Appendicitis Injury
Past Cholecystitis Burn
Medical & Other:____________________ Stab/Laceration
Surgical Fracture
History
Have you ever been admitted to the hospital and/or underwent a surgery?
No Yes
Year:___________ Reason/s:________________________
Year:___________ Reason/s:________________________
Year:___________ Reason/s:________________________
Indicate the known health condition/s of your immediate family members.
Hypertension (elevated blood pressure)

Coronary Artery Disease
Congestive Heart Failure
Diabetes mellitus (elevated blood sugar)
Chronic Kidney Disease (with/without regular Hemodialysis)
Dyslipidemia (elevated cholesterol levels)
Arthritis (joint pains)
Cancer (Specify:________________________)
Family Bronchial Asthma ("Hika")
Medical Chronic Obstructive Pulmonary Disease (COPD)
History
Food Allergies (Specify food:___________________________)
Allergic Rhinitis
Hyperthyroidism
Hypothyroidism/Goiter
Psychiatric Illness:
Major Depressive Disorder
Bipolar Disorder
Generalized Anxiety Disorder
Panic Disorder
Posttraumatic Stress Disorder
Schizophrenia
Other: ____________________________________
Epilepsy/Seizures
Other: _____________________________________________________
(For use by the University Health Services Center. Please do not fill out beyond this point.)
Height (cm): Weight (kg): BMI:
Physical Examination:
Pre-Enrollment Health Assessment:
Chest X-ray Results: ____________________________________________________________________
CBC Results:___________________________________________________________________________
Blood Type:_________ Hepatitis B Screening Results (Antigen Test):_________________________
Urinalysis Results: ______________________________________________________________________
Others: ________________________________________________________________________________
CONSULTATIONS RECORD
Date Nurse/
Signs & Symptoms Vital Signs Test Results Diagnosis Management
(mm-dd-yy) Physician In-charge
HR:
RR:
Temp:
O2 sat:
BP:
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WESTERN MINDANAO STATE UNIVERSITY

PATIENT HEALTH PROFILE & CONSULTATIONS RECORD

(Surname) (First name) (Middle name)

Age: 18 Sex: Male Course: BS in Electrical Engineering

Birthday (MM-DD-YY): 07-20-2005 Religion: Roman Catholic

Nationality: Filipino Civil Status: Single

Email Address: barcelonaaj20@gmail.com Contact #: 09919670468

Provincial Address (if applicable):

Emergency Name: Erlinda G. Barcelona

Which of these conditions do you currently have?

Migraine (recurrent headaches)

Generic Name of Drug Dose and Frequency

Fully vaccinated (Primary series with or without booster shot/s)

Age when menstruation began: ________ Menstrual Symptoms:

Varicella (Chicken Pox) Measles

Indicate the known health condition/s of your immediate family members.

Hypertension (elevated blood pressure)

Height (cm): Weight (kg): BMI:

Pre-Enrollment Health Assessment:

Chest X-ray Results: ____________________________________________________________________

Blood Type:_________ Hepatitis B Screening Results (Antigen Test):_________________________

Urinalysis Results: ______________________________________________________________________

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Blood Type:_ Hepatitis B Screening Results (Antigen Test):_________________