AHS-M-006 ATENEO DE MANILA UNIVERSITY

ATENEO HIGH SCHOOL HEALTH SERVICES

STUDENTS 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: ______________ Cellphone: ____________________________________

Person to contact in case of emergency: __________________________________________ Cellphone: ____________________________________

Personal Physician: ___________________________________ Clinic phone: _____________ Office phone: __________________________________

MEDICAL HISTORY (To be completed by student or parents. Explain YES answer in the space provided below. Encircle questions you dont know answers to.)

YES NO YES NO

1. Has a doctor ever denied or restricted your participation

in sports or any physical activity for any reason?

2. Have you had medical illness or injury since your last

medical check-up or sports physical examination?

3. Do you have an ongoing medical condition (i.e., diabetes,

asthma or sickle cell anemia, etc..)?

4. Have you ever been hospitalized for 1 or more days?

5. Are you currently taking any prescription or over-the-counter

medication or using an inhaler?

6. Do you have any allergies to pollen, latex, medicines, food,

insects, etc? If yes, please specify allergy below.

7. Any past surgical operation, accidents or non-sports

related injuries?

8. Have you ever musculoskeletal injury like sprain,

muscle or ligament tear, tendonitis, fractured bones or

Dislocated joints? If yes, please put below.

9. Have you had a bone or joint injury that required x-rays, MRI, CT scan,

surgery, injections, rehabilitation, physical therapy session, use of brace,

cast or crutches? If yes, please encircle affected area below.

Head Chest Elbow Hand Thigh Ankle

Neck Shoulder Forearm Finger Knee Foot

Back Upper arm Wrist Hip Shin/calf Toe

YES NO

10. Does anyone in your family have a heart problem?

11. Has anyone in your family die of heart problem or

sudden death before the age of 50?

12. 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?

19.Has a doctor ever told you that you have: (Check all that apply)

High Blood Pressure Heart Murmur

High Cholesterol Heart Infection

20.Has a doctor ever ordered a test for your heart (i.e. ECG

or echocardiogram)?

21.Have you had a severe viral infection (i.e. myocarditis or

mononucleosis) within the last month?

22. Has a doctor told you that you have asthma?

23.Do you cough, wheeze or have difficulty of breathing

during or after exercise?

24. Have you ever had a head injury or concussion?

25.Have you ever been knocked out, became unconscious or

lost your memory?

26. Have you ever had seizure?

27. Do you have frequent or severe headaches?

28.Have you ever had numbness or tingling sensation in your

face, arms, hands, legs or feet?

29.Have you ever been unable to move your arms or legs

after being hit or after falling?

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

cramps or become ill?

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

one kidney, blindness in one eye, one testicle, etc.)?

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

the groin area?

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

devices that are not usually used for your sport or position

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

retainers or hearing aid)?

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

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

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

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

go on a kind of diet?

38. Do you need to lose weight regularly to meet weight

requirement or your sport?

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

with a doctor?

40. Check which immunization were given and the member of

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

if available:

Tetanus: ______ MMR: ________ Hepatitis B: _________

Tdap: _______ Chicken: ________ Flu: _______________

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.

_________________________________ ______________________________________ ___________________

Students Signature Parent/Guardians Signature Date

1 x 1 Photo

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)

Students 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: ____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Physicians Name and Signature: ______________________________________________ Date: ________________________

License Number: ___________________________ Cellphone: ____________________

Address: __________________________________________________________________ Clinic Phone: __________________

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

AHS-D-001

ATENEO DE MANILA HIGH SCHOOL

DENTAL HEALTH SERVICES

DENTAL EXAMINATION RECORD

Name of Student _____________________________________________ Year & Section __________ Date ____________

Surname First Name M.I

DENTAL HEALTH STATUS:

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

Dentofacial Anomaly, Neoplasm, Others, specify: _______________________________________ __________________________________________ __________________________________________

DENTAL/ORAL EXAMINATION REVEALED THE FOLLOWING CONDITIONS AND RECOMMENDATIONS. ___________ Caries Free __________Needs Prosthesis (Denture)

___________ Poor Oral Hygiene (Materia Alba, Calculus, Stain) __________For Endodontic Treatment

___________ Indicated for Restoration/Filling __________For Orthodontic Consultation

___________ Indicated for Extraction __________For Pits and Fissures Sealant Application

___________ Gingival inflammation __________Others

___________ Needs Oral Prophylaxis __________No Dental Treatment Needed at Present

TO: THE EXAMINING DENTIST

Please accomplish the treatment needed and provide other dental history of the patient. Kindly sign and send back this form for inspection to the Ateneo de Manila

High School Dental Health Services.

Dental Treatment Given: ______________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

_______________________________________

Dentist Signature over Printed Name

License no.___________

55 54 53 52 51 61 62 63 64 65

85 84 83 82 81 71 72 73 74 75

ORAL HEALTH CONDITION

Date of Examination

Age last birthday

Presence of Debris Y N Y N

Inflammation of Gingiva Y N Y N

Presence of Calculus Y N Y N

Under Orthodontic Treatment Y N Y N

INITIAL SOFT TISSUE EXAM

Lips Floor of Mouth Palate Tongue Neck & Nodes

INITIAL PERIODONTAL EXAM

GINGIVAL INFLAMATION: Slight Moderate Severe

SOFT PLAQUE BUILDUP: Slight Moderate Heavy

HARD CALC BUILDUP: Light Moderate Heavy

STAINS: Light Moderate Heavy

HOME CARE EFFECTIVENESS: Good Fair Poor

PERIODONTAL CONDITION: Good Fair Poor

PERIODONTAL DIAGNOSIS: Normal Gingivitis

PERIODONTITIS: Early Moderate Advanced

MUCOGINGIVAL DEFECTS:

CLINICAL DATA

OCCLUSION: Class 1 Class II Class III

T.M.J. EXAM: Pain Popping Deviation Tooth Wear

TOOTH COUNT T P T P

Number of Teeth Present

Number of Caries Free Teeth

Number of Decayed Teeth

Number of Missing Teeth

Number of Filled Teeth

Total df &DMF Teeth

Consent to Treatment

I hereby grant permission to the staff, physicians, and dentist of the Ateneo de Manila High School Health Services to render my son any medical and/or dental treatment that they deem necessary as part of first aid treatment especially during but not limited to emergency cases. I understand that the Ateneo de Manila High School Health Services will make all possible effort to inform me in the event of such treatment in an emergency.

By signing below, I attest that the information contained herein is correct to the best of my knowledge and that I have read the CONSENT TO TREATMENT provision above, fully understand their terms, and sign below freely and voluntarily without any inducement. I further acknowledge that I am the parent or legal guardian of the student.

Parent / Legal Guardian Name (PRINT) Parent / Legal Guardian SIGNATURE

Date: MM / DD / YYYY Students Signature Over Printed Name