Republic of the Philippines

POLYTECHNIC UNIVERSITY OF THE PHILIPPINES

Office of the Vice President for Administration
Medical Services Department

MEDICAL PATIENTS RECORD WITH PARENTS / LEGAL GUARDIANS CONSENT

(TO BE FILLED-UP BY STUDENT)

PERSONAL INFORMATION
Name: Date:

Address: Age: Sex:

Contact No.: Birthday: Citizenship:

Contact Person In Case of Emergency. (Relationship) Contact No.:

(TO BE FILLED-UP BY MEDICAL STAFF)

CXR: ( ) NORMAL ( ) OTHERS:

(TO BE FILLED UP BY PARENT/ LEGAL GUARDIAN)

INFORMANTS NAME & RELATIONSHIP TO STUDENT:

I. PAST MEDICAL HISTORY RELATED TO STUDENT: II. FAMILY HISTORY

Cancer Asthma Tuberculosis Cancer Asthma Tuberculosis

( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No
HIV Liver Disorder Diabetes HIV Liver Disorder Diabetes
( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No
Alcoholism Heart Trouble Emphysema/COPD Alcoholism Heart Trouble Emphysema/COPD
( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No
Birth Defects Heart Attack Ulcers Birth Defects Heart Attack Ulcers
( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No
Kidney Disease High Blood Pressure Stroke Kidney Disease High Blood Pressure Stroke
( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No
Gout Cholesterol Sickle Cell Anemia Gout Cholesterol Sickle Cell Anemia
( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No
Seizure/ Epilepsy Arthritis Bleeding Disorder Seizure/Epilepsy Arthritis Bleeding Disorder
( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No
Other Diseases Please Specify: ( ) Yes ( ) No

SURGERY: ( ) Yes ( ) No If yes, what type of procedure?

FRACTURES: ( ) Yes ( ) No If yes, what type of fracture?
MEDICATION: ( ) Yes ( ) No If yes, for what type of illness?
Any food/drug other allergies: ( ) Yes ( ) No What kind:

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 Republic of the Philippines
POLYTECHNIC UNIVERSITY OF THE PHILIPPINES
Office of the Vice President for Administration
Medical Services Department

MEDICAL CONSENT

I being the parent/ legal guardian of ______________________________, declare that I

understand that he/she will be involved in activities outside the University, thus exposing my
son/daughter to situations and physical activity not encountered in a classroom/school.

I acknowledge that while the University, its medical staff, associated instructors and
volunteers will make every reasonable effort to minimize exposure to known risks, all hazards
and dangers associated with these activities cannot be foreseen or may be beyond the control
of the PUP, its medical staff, volunteers and associated instructors.

In the event that it is not possible or reasonable for myself or the above emergency
contact to give treatment consent, and the above mentioned student requires medical
assistance or attention, I authorize a representative of the University to arrange for the
appropriate care. In this event, I agree to pay all such emergency evacuation, ambulance,
doctor, nurse and/or hospital expenses.

I understand that it is the parents/legal guardians responsibility to provide the medical

information requested on this form and to advise the University in writing, in a timely fashion, if
this information changes. It is the responsibility of the parent/legal guardian to update the
students medical details.

The Polytechnic University of the Philippines (PUP)/Medical Services Department (MSD)

and its medical staff accepts no responsibility for any outcomes from information contained in
this Medical Patients Record/Form being incomplete or inaccurate.

_______________________________ _______________________
SIGNED BY PARENT / LEGAL GUARDIAN DATE

Note: FALSIFICATION OF PARENTS / GUARDIANS SIGNATURE WILL BE SUBJECTED TO, BUT NOT
LIMITED TO SCHOOL / UNIVERSITY DISCIPLINARY ACTIONS.

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