PUP-HIFS-6-MEDS-028
Rev.0
June 26, 2024
Republic of the Philippines
POLYTECHNIC UNIVERSITY OF THE PHILIPPINES
Office of the Vice President for Administration
MEDICAL SERVICES DEPARTMENT
HEALTH INFORMATION FORM FOR STUDENTS
PART I. STUDENT INFORMATION
Name: _______________________________________________________________ PUP Student No.:___________________________
Home: Address: _______________________________________________________ School Year: _______________________________
Age: ______________ Sex: ________________ Civil Status: ____________ Course/ College: ___________________________________
Blood Type: ___________________________________________________ Email Address: ____________________________________
Parent’s Name/ Guardian/ Spouse: _________________________________________________________________________________
Landline:______________________________________________________ Cellphone: _______________________________________
PART II. MEDICAL HISTORY
1. Do you need medical attention or has known medical illness? No Yes
(Please check the following that apply as needed)
Asthma Loss of Consciousness Eye Disease/ Defect Accident Injuries
Diabetes Heart Disease Kidney Disease Tuberculosis /
Convulsion/ Epilepsy Hyperventilation Hemophilia Primary Complex
Migraine High Blood Pressure
Others (Pls. Indicate): ____________________________________________________________________________
2. Do you have disability? None Yes, What type of disability? ___________________________________
3. Additional Information for Students and Medical Conditions:
As a Parent/ Guardian, I would like to declare that my child has history of allergies to the following:
Food(Please specify): _____________________________________________ No Known Allergies: _______________________
Medicines: Aspirin Ibuprofen Amoxicillin
Mefenamic Acid Penicillin Others: _________________________
PART III. PERSONAL SOCIAL HISTORY
Cigarette Smoking: Yes No
Alcohol Drinking Yes No
4. COVID-19 Vaccination History: Vaccinated: Yes No If Yes (Vaccinated) Date Received Brand
1st dose
2nd dose
Booster 1st dose
Booster 2nd dose
I hereby certify that the medical health information given to PUP Medical Services are true, correct and fully disclosed to the best of
my knowledge and all the medical condition that may affect in the assessment for purpose of consultation/ issuance of medical
clearance/ certificate as a student of PUP.
I also understand that the PUP MSD and university will not be liable for any untoward incident that may arise due to any failure to
disclose accurate information or intentionally providing false and deceptive information.
In compliance with the Data Privacy Act of 2012 and its IRR, I voluntarily consent to the collection, processing and storage of my
personal and health information for the purpose/s of health assessment/ treatment/ or research following research ethics guidelines
for the improvement of healthcare services.
(Signature of parent/guardian for (Printed and signature of student) Date
students below 18 years old)
For Physician Only
Please Check
Medical Clearance: Issued Pending, Reason: ____________________________________________
Date: Physician’s name and signature
