ATENEO DE MANILA UNIVERSITY



AHS-M-006

ATENEO DE MANILA UNIVERSITY

ATENEO HIGH SCHOOL HEALTH SERVICES

STUDENT’S HEALTH INFORMATION SY ____________

Please answer this form as accurate as possible. All the information contained within will be kept confidential.

STUDENT INFORMATION

Name: _____________________________________________________________________ Sex: ______ Age: _______ Date of Birth: ____/____/____

Year & Sec.: ___________ ID Number: _______________________ Cell phone: ____________________________

Home Address: _________________________________________________________________________ Home Phone: ___________________________

________________________________________________________________________________________________________________________________

Name of Parent/ Guardian: _______________________________________________________________ Home phone: ___________________________

Email Address: __________________________________________ Work phone: ___________________ Cell phone: _____________________________

Person to contact in case of emergency: _____________________________________________________ Cell phone: _____________________________

Personal Physician: _______________________________________ Clinic: ________________________ Office phone: ___________________________

MEDICAL HISTORY (To be completed by student or parents. Explain YES answer in the space provided below. Encircle questions you don’t know answers to.)

| | |

|YES NO |YES NO |

|1. Has a doctor ever denied or restricted your participation |19.Has a doctor ever told you that you have: (Check all that apply) |

|in sports or any physical activity for any reason?   | High Blood Pressure  Heart Murmur |

|2. Have you had medical illness or injury since your last | High Cholesterol  Heart Infection |

|medical check-up or sports physical examination?   |20.Has a doctor ever ordered a test for your heart (i.e. ECG |

|3. Do you have an ongoing medical condition (i.e., diabetes, |or echocardiogram)?   |

|asthma or sickle cell anemia, etc..)?   |21.Have you had a severe viral infection (i.e. myocarditis or |

|4. Have you ever been hospitalized for 1 or more days?   |mononucleosis) within the last month?   |

|5. Are you currently taking any prescription or over-the-counter |22.Has a doctor told you that you have asthma?   |

|medication or using an inhaler?   | |

|6. Do you have any allergies to pollen, latex, medicines, food, |23.Do you cough, wheeze or have difficulty of breathing |

|insects, etc? If yes, please specify allergy below.   |during or after exercise?   |

|7. Any past surgical operation, accidents or non-sports |24.Have you ever had a head injury or concussion?   |

|related injuries? |25.Have you ever been knocked out, became unconscious or |

|  |lost your memory?   |

|8. Have you ever musculoskeletal injury like sprain, |26.Have you ever had seizure?   |

|muscle or ligament tear, tendonitis, fractured bones or |27.Do you have frequent or severe headaches?   |

|Dislocated joints? If yes, please put [pic] below. |28.Have you ever had numbness or tingling sensation in your |

|9. Have you had a bone or joint injury that required x-rays, MRI, CT scan, surgery,|face, arms, hands, legs or feet?   |

|injections, rehabilitation, physical therapy session, use of brace, cast or |29.Have you ever been unable to move your arms or legs |

|crutches? If yes, please encircle affected area below. |after being hit or after falling?   |

| |30.When exercising in the heat, do you have severe muscle |

|Head |cramps or become ill?   |

|Chest |31.Any known deformities (i.e. scoliosis, heart problem, |

|Elbow |one kidney, blindness in one eye, one testicle, etc.)?   |

|Hand |32.Do you have groin pain or painful bulge or hernia in |

|Thigh |the groin area? |

|Ankle |  |

| |33.Do you use any protective/corrective equipment or medical |

|Neck |devices that are not usually used for your sport or position |

|Shoulder |(i.e. knee brace, special neck roll, foot orthosis, shunt, teeth |

|Forearm |retainers or hearing aid)?   |

|Finger |34. Have you had any problems with your eyes or vision?   |

|Knee |31. Do you wear glasses, contact lenses or protective eyewear?  |

|Foot |36. Do you want a weight more or less than you do now?   |

| |37. Do you limit or carefully control what you eat or |

|Back |go on a kind of diet?  |

|Upper arm | |

|Wrist |38. Do you need to lose weight regularly to meet weight |

|Hip |requirement or your sport?   |

|Shin/calf | |

|Toe |39. Do you have any concerns that you would like to discuss |

| |with a doctor? |

|YES NO |  |

|Does anyone in your family have a heart problem?   |40. Check which immunization were given and the member of |

| |dose (s) received. Attach original/Xerox copy of immunization |

|Has anyone in your family die of heart problem or |if available: |

|sudden death before the age of 50?   |Tetanus: ______ MMR: ________ Hepatitis B: _________ |

| |Tdap: _______ Chicken: ________ Flu: _______________ |

|Any serious family illness (i.e. diabetes, bleeding | |

|disorder, etc)?  | |

| | |

|13Any family history of cancer? Note the kind | |

|of cancer below.  | |

| | |

|14.Have you ever had a rash or hives develop during or | |

|after exercise?  | |

| | |

|15.Have you ever passed out or been dizzy during or | |

|after exercise?  | |

| | |

|16.Have you ever experienced/ felt discomfort, pain or | |

|pressure in your chest during exercise?   | |

| | |

|17.Do you get tired more quickly than your friends do during | |

|exercise?   | |

|18.Does your heart race faster than normal or skip beats | |

|(irregular beats) during exercise?   | |

Explain YES answers here: (Attach additional sheets as needed.)

_________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

We certify that our answers to the above questions are complete and correct to the best of our knowledge.

_________________________________ ___________________________________ ___________________

Student’s Signature Parent/Guardian’s Signature Date

Additional questions on more sensitive issues. YES NO

_____________________________________________________________________________________________________________________

Do you feel safe?  

Do you ever feel sad, hopeless, depressed, or anxious?  

Have you ever tried cigarette smoking, even one or two puffs? Do you currently smoke?  

Do you take alcoholic drinks or use prohibited drugs (i.e. marijuana, cocaine, etc.)?  

Have you ever taken steroids or used any other performance supplement?  

Have you ever taken any supplements or vitamins to help you gain or lose weight or improve

your performance?  

Explain YES answers here: (Attach additional sheets as needed.)

_____________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PHYSICAL EXAMINATION (To be completed by physician)

Student’s Name: ___________________________________________________________________

Height: ___________ Weight: ____________ Pulse rate: __________ RR: __________ BP: ___________ Temp. ___________

Vision: Right 20/______ Left: 20/_______ Corrected:  YES  NO Pupils:  Equal  Unequal

NORMAL ABNORMAL FINDINGS

1. General Appearance ______________ __________________________________________

2. Head ______________ __________________________________________

3. EENT ______________ __________________________________________

4. Lungs ______________ __________________________________________

5. Heart * ______________ __________________________________________

6. Abdomen ______________ __________________________________________

7. Genitourinary * ______________ __________________________________________

8. Skin ______________ _________________________________________

9. Lymph Nodes ______________ __________________________________________

10. Peripheral pulses ______________ __________________________________________

11. Neurologic Exam * ______________ __________________________________________

12. Musculoskeletal * ______________ __________________________________________

a. Neck ______________ __________________________________________

b. Back ______________ __________________________________________

c. Shoulder/Arm ______________ __________________________________________

d. Elbow/Forearm ______________ __________________________________________

e. Wrist/Hand ______________ __________________________________________

f. Hip/Thigh ______________ __________________________________________

g. Knee ______________ __________________________________________

h. Shin/Calf ______________ __________________________________________

i. Ankle/Leg ______________ __________________________________________

j. Foot ______________ __________________________________________

* Consider doing additional test for abnormal findings on history or physical exam (e.g., ECG, echocardiogram for

Abnormal cardiac findings, GU exam, cognitive evaluation / baseline neuropsychiatric testing or x-rays).

ASSESSMENT OF EXAMINING PHYSICIAN

I certify that the above examination was done with the following conclusion(s):

 Cleared without limitations.

 Cleared with precautions.

 Cleared after completing evaluation/rehabilitation for ____________________________________________________.

 Not cleared for ______________________________ Reason: _____________________________________________

Recommendations: ____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Physician’s Name and Signature________________________________________ Date _____________________

Address _____________________________________________________________ Contact No __________________

Modified from American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. 2010.

REVISED 2014

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1 x 1 Photo

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