Form No.

07-OPD-008, Revised, May 2018

UNIVERSITY HEALTH SERVICE
University of the Philippines Los Baños
Tel. Nos.: (049) 536-3247; 536-2470
Philhealth Accredited Health Care Provider

PRE–ENROLMENT MEDICAL EXAMINATION REPORT

(Use blue or black permanent ink. DO NOT USE sign pens. Print on size A4 paper back-to-back, 2nd page is upside down.)
PERSONAL INFORMATION
Name:_______________________________________________________________________________ UHS ID No.: __________________________________
(Last) (First) (Middle) (c/o UPLB-UHS)

Date of Birth:_____________________________ Age:_______ Sex:_______Civil Status:_____________ Nationality: ___________________________________

Home Address:______________________________________________________________ Tel. No/s. (landline and mobile):_________________________________
College:____________________________________________ Degree:___________________________Student No:___________________________________
Name of  Spouse  Parent  Guardian:_____________________________________________________________________________________________
Address:___________________________________________________________________ Tel. No/s. (landline and mobile):_________________________________

MEDICAL HISTORY (Do not leave blank areas. Write either : NA or Not Applicable; Unrecalled; or, None)
Specific Disease / Specific Disease /
Disease Details Disease Details
Remarks Remarks
Allergy, food / medication Head / Neck injury

Heart Disease (rheumatic heart

Asthma, bronchial / skin
disease, hypertension,…)
Kidney disease
Blood dyscrasia
(polycystic kidney, lithiasis,…)
Liver disease
Cancer / Tumor
(hepatitis, cirrhosis,…)
Congenital anomaly / Lung disease
deformity (PTB, COPD, pneumonia…)
Endocrine disorders (diabetes Neurologic disorders (fainting spells,
mellitus, thyroid disorders,…) seizures, mental disorders,…)
ENT disorders (ear, nose, Viral infections
throat) (chicken pox, measles,…)

Gastrointestinal disorders
Others (eg G6PD deficiency,…)
Genito-urinary (STD, UTI)

OPERATIONS CURRENT MEDICATIONS TAKEN

 Chicken pox_____________  Hepatitis A ___________  MMR _______________  Meningococcemia________________

IMMUNIZATIONS
(Indicate month & year given)
 Pneumonia______________  Hepatitis B ___________  Tetanus toxoid___________  HPV vaccine ____________________
 Influenza _______________  Typhoid______________  Rabies ___________________  Others _________________________

FAMILY HISTORY PERSONAL AND SOCIAL HISTORY:

 Asthma  Diabetes mellitus  Thyroid disease  Smoking ( ______ sticks/day for _______ year/s)
 Blood dyscrasia  Heart disease  Tuberculosis
 Cancer  Drinking (______ beer per ____________; ______ shots per __________)
 Hypertension  Others
MENSTRUAL Menarche Duration Interval Pads/day Menstrual Symptoms
 Regular
HISTORY  Irregular
Over the past 2 weeks, how often have you been bothered by Several More than Nearly
Not at all TOTAL
any of the following? Please encircle your self-assessment. days 1 week every day
PSYCHO-
EMOTIONAL Little interest or pleasure in doing things 0 1 2 3
STATUS
Feeling down, depressed, or hopeless 0 1 2 3

I hereby certify that the foregoing answers are true

and complete, and to the best of my knowledge. _____________________ ____________________________ ___________________
Patient’s Signature Parent/Guardian’s Signature Above Printed Name Date Signed
DO NOT WRITE BELOW THIS LINE (to be accomplished by the medical staff only)
VITAL SIGNS ANTHROPOMETRICS Uncorrected Corrected
VISUAL ACUITY
OD OS OD OS
BP: 1st _____/_____mmHg 2nd_____/_____mmHg Height: ______meters
Near Vision
PR: _______/minute RR: _______/minute Weight:______kgs
Far Vision
Temp: ________oC BMI:______________
Ishihara Test  Positive  Negative

CHEST X-RAY FINDINGS CBC RESULTS

Impression: Results:

This form has been conceptualized and developed by the University Health Service for the students of U.P. Los Baños. Use of its
format and contents shall be subject to permission from the authorities of UHS-UPLB.
This page is to be printed upside down at the back of the 1 st page.

Name:__________________________________________________ Date of Birth:_________________ Age:____ Sex:____ UHS ID No.: _______________

(Last) (First) (Middle) (c/o UPLB-UHS)

PHYSICAL EXAMINATION
Findings E/N Findings Description & Other Findings
General appearance, body built

 Discoloration  Congenital marks
Skin 
 Lesion  Deformity
 Deformity
Head 
 Lesion (acne)
Eyes   Inflammation
  Hearing Acuity:  Deformity
Ears  R_______ L_______  Discharge
 Dryness
 Deformity  Bleeding
Nose 
 Ulcer/Lesion  Discharge
 Inflammation  Ulcer/Lesion
Mouth & Tongue 
 Tongue Deviation  Deformity
 Foul odor  Ulcer/Lesion
Throat, Pharynx & Tonsils 
 Inflammation  Swelling
 Rigidity  Tenderness
Neck & Lymph Nodes 
 Swelling/Mass  Fistula
 Mass/es
Thyroid  Diffuse enlargement

 Irregular beat / rhythm
Heart   Abnormal Rate
 Murmur
 Tenderness  Deformity
Chest 
 Bulges/Depression  Retraction
 Wheezing  Stridor
Lungs 
 Rales/Crackles
 Retraction/Dimpling  Mass/Nodule
Breast & Axilla 
 Enlarged lymph nodes  Discharge
 Striae  Mass/es
Abdomen 
 Tenderness  Distention
 Tenderness  Deformity
Back & Shoulder   Scoliosis  Kyphosis
 Lordosis
 Deformity  Edema
Extremities   Tremors
 Clubbing of nails
 Lesion  Mass/es
Anus & Rectum 
 Tenderness  Stricture
 Deformity  Lesion
FOR MALES: Penis   Phimosis  Edema
 Profuse Discharge  Circumcised
 Maldescended testis  Lesion
Scrotum   Edema  Tenderness
 Hernia
 Developmental anomalies  Lesion
FOR FEMALES: Genitalia   Inflammation  Discharge
 Purulent Discharge  Swelling
Other significant findings

FITNESS CERTIFICATION

 Fit for enrollment  Not fit for enrollment  Pending, reason: _____________________________________________________________
Impression/s: Recommendation/s:

____________________________________________________ ________________________ ________________________ ________________________

Signature Above Printed Name of Attending Physician License No. PTR No. Date of Examination

*NOTE: Please issue a separate Medical Certificate using your official letterhead.

FOR UHS PHYSICIAN’S VALIDATION ONLY

The above findings are certified correct and are based on the physical examination, diagnostic results available, and the disclosure of the patient’s
pertinent medical history at the time and date of examination.

____________________________________________________ ________________________ ________________________

Signature Above Printed Name of Attending Physician License No. Date of Examination

This form has been conceptualized and developed by the University Health Service for the students of U.P. Los Baños. Use of its
format and contents shall be subject to permission from the authorities of UHS-UPLB.